●
Unit
Contents
1
Basic Concepts in Nursing Practice
2
1 Health Care Delivery and Nursing Practice
4
Nursing Defined 5 The Patient/Client: Consumer of Nursing and Health Care Health Care in Transition 6
HEALTH, WELLNESS, AND HEALTH PROMOTION
5
Ethics Versus Morality 28 Ethics Theories 29 Approaches to Ethics 29 Moral Situations 30 Types of Ethical Problems in Nursing
6
PREVENTIVE ETHICS Advance Directives
15
Team Nursing 15 Primary Nursing 15 Community-Based Nursing and Community Health–Public Health Nursing 16
33
16
HEALTH EDUCATION TODAY
2 Community-Based Nursing Practice
45 46
The Purpose of Health Education
19
THE GROWING NEED FOR COMMUNITY-BASED HEALTH CARE 20
HOSPITAL AND COMMUNITY-BASED NURSING 21 DISCHARGE PLANNING FOR HOME CARE 22 COMMUNITY RESOURCES AND REFERRALS 22 PREPARING FOR A HOME VISIT 22 CONDUCTING A HOME VISIT 22
46
ADHERENCE TO THE THERAPEUTIC REGIMEN 46 THE NATURE OF TEACHING AND LEARNING 47 Learning Readiness 47 The Learning Environment 48 Teaching Techniques 49 Teaching People With Disabilities
Community-Based Care 20 Home Health Care 21
49
THE NURSING PROCESS IN PATIENT TEACHING
51
Assessment 51 Nursing Diagnosis 51 Planning 51 Implementation 52 Evaluation 52
HEALTH PROMOTION 23
OTHER COMMUNITY-BASED HEALTH CARE SETTINGS
41
4 Health Education and Health Promotion
17
Ambulatory Settings 24
30
33
Assessment 34 Diagnosis 37 Planning 37 Implementation 40 Evaluation 40 Documentation of Outcomes and Revision of Plan
Practitioner Role 14 Leadership Role 15 Research Role 15
Personal Safety Precautions 22 Initial Home Visit 23 Determining the Need for Future Visits Closing the Visit 24
27
ETHICAL DECISION MAKING 34 STEPS OF THE NURSING PROCESS 34 USING THE NURSING PROCESS 34
ROLES OF THE NURSE 14
MODELS OF NURSING CARE DELIVERY
26
ETHICAL NURSING CARE 28 DOMAIN OF NURSING ETHICS 28
6
Population Demographics 7 Changing Patterns of Disease 7 Advances in Technology and Genetics 8 Economic Changes 8 Demand for Quality Care 8 Alternative Health Care Delivery Systems 9
Collaborative Practice
3 Critical Thinking, Ethical Decision Making, and the Nursing Process Rationality and Insight 27 Components of Critical Thinking 27 Critical Thinking in Nursing Practice 27
6
INFLUENCES ON HEALTH CARE DELIVERY
EXPANDED NURSING ROLES
24
DEFINITION OF CRITICAL THINKING CRITICAL THINKING PROCESS 27
THE HEALTH CARE INDUSTRY AND THE NURSING PROFESSION 5
Health 6 Wellness 6 Health Promotion
Occupational Health Programs School Health Programs 24 Care for the Homeless 25
24
52
Health and Wellness 53 Health Promotion Models 53 Definition of Health Promotion 53 Health Promotion Principles 54 xvii
Contents
xviii
HEALTH PROMOTION THROUGHOUT THE LIFE SPAN 54 Children and Adolescents 55 Young and Middle-Aged Adults Elderly Adults 55
55
IMPLICATIONS FOR NURSING 56
5 Health Assessment
59
THE ROLE OF THE NURSE IN ASSESSMENT BASIC GUIDELINES FOR CONDUCTING A HEALTH ASSESSMENT 60 ETHICAL USE OF HISTORY OR PHYSICAL EXAMINATION DATA 60 THE HEALTH HISTORY 60
60
67
ASSESSMENT IN THE HOME AND COMMUNITY
DEFINITIONS OF CULTURE Subcultures and Minorities
74
Biophysical and Psychosocial Concepts in Nursing Practice
78
6 Homeostasis, Stress, and Adaptation STRESS AND FUNCTION 81 DYNAMIC BALANCE: THE STEADY STATE 81 82
STRESSORS: THREATS TO THE STEADY STATE
82
80
113
115
115
CULTURALLY MEDIATED CHARACTERISTICS Space and Distance 116 Eye Contact 117 Time 117 Touch 117 Communication 118 Observance of Holidays 118 Diet 118 Biologic Variations 119 Complementary and Alternative Therapies
CAUSES OF ILLNESS
101
114
Cross-Cultural Communication 72
99
114
TRANSCULTURAL NURSING 115 CULTURALLY COMPETENT NURSING CARE
2
Types of Stressors 82 Stress as a Stimulus for Disease 83 Psychological Responses to Stress 83 Physiologic Response to Stress 84 Maladaptive Responses to Stress 87 Indicators of Stress 87 Nursing Implications 88
93
96
8 Perspectives in Transcultural Nursing
69
Historical Theories of the Steady State Stress and Adaptation 82
STRESS MANAGEMENT: NURSING INTERVENTIONS
HOLISTIC APPROACH TO HEALTH AND HEALTH CARE 100 THE BRAIN AND PHYSICAL AND EMOTIONAL HEALTH 100 EMOTIONAL HEALTH AND EMOTIONAL DISTRESS FAMILY HEALTH AND DISTRESS 102 ANXIETY 103 POSTTRAUMATIC STRESS DISORDER 104 DEPRESSION 105 SUBSTANCE ABUSE 107 LOSS AND GRIEF 108 DEATH AND DYING 109 SPIRITUALITY AND SPIRITUAL DISTRESS 109
Body Mass Index 70 Biochemical Assessment 71 Clinical Examination 71 Dietary Data 71 Conducting the Dietary Interview 71 Evaluating the Dietary Information 72 Factors Influencing Nutritional Status in Varied Situations Analysis of Nutritional Status 74
Unit
92
7 Individual and Family Considerations Related to Illness
Inspection 67 Palpation 68 Percussion 68 Auscultation 69
NUTRITIONAL ASSESSMENT
88
Control of the Steady State 88 Cellular Adaptation 89 Cellular Injury 90 Cellular Response to Injury: Inflammation Cellular Healing 93 Nursing Implications 93
Promoting a Healthy Lifestyle 94 Enhancing Coping Strategies 94 Teaching Relaxation Techniques 94 Educating About Stress Management 95 Enhancing Social Support 96 Recommending Support and Therapy Groups
The Informant 61 Cultural Considerations 61 Content of the Health History 61 Past Life Events Related to Health 62 Education and Occupation 63 Environment 63 Lifestyle 65 Physical or Mental Disability 65 Self-Concept 65 Sexuality 65 Risk for Abuse 66 Stress and Coping Responses 66 Other Health History Formats 66
PHYSICAL ASSESSMENT
STRESS AT THE CELLULAR LEVEL
116
119
119
Biomedical or Scientific 119 Naturalistic or Holistic 120 Magico-Religious 120
FOLK HEALERS 120 CULTURAL ASSESSMENT 120 ADDITIONAL CULTURAL CONSIDERATIONS: KNOW THYSELF 121 THE FUTURE OF TRANSCULTURAL NURSING CARE 121
9 Genetics Perspectives in Nursing
A FRAMEWORK FOR INTEGRATING GENETICS INTO NURSING PRACTICE 124
123
Contents GENETICS CONCEPTS
125
Genes and Their Role in Human Variation 126 Inheritance Patterns in Families 128 Chromosomal Differences and Genetic Conditions
CLINICAL APPLICATIONS OF GENETICS
PHYSICAL HEALTH PROBLEMS IN OLDER POPULATIONS 201 Geriatric Syndromes: Multiple Problems With Multiple Etiologic Factors 201 Acquired Immunodeficiency Syndrome in Older Adults
132
132
Genetic Testing 132 Genetic Screening 133 Testing and Screening for Adult-Onset Conditions Individualizing Genetic Profiles 137
133
THE OLDER ADULT IN AN ACUTE CARE SETTING: ALTERED RESPONSES TO ILLNESS 210
143
THE PHENOMENON OF CHRONICITY
Increased Susceptibility to Infection 210 Altered Pain and Febrile Responses 211 Altered Emotional Impact 211 Altered Systemic Response 211
146 147
Definition of Chronic Conditions 147 Prevalence and Causes of Chronic Conditions
147
THE CHARACTERISTICS OF CHRONIC CONDITIONS
149
The Problems of Managing Chronic Conditions 150 Implications for Nursing 151 Phases of Chronic Illness 151 Care by Phase: Applying the Nursing Process 152
PROMOTING HOME AND COMMUNITY-BASED CARE Teaching Patients Self-Care 155 Continuing Care 155 Nursing Care for Special Populations With Chronic Illness
11 Principles and Practices of Rehabilitation
155 155
158
AMERICANS WITH DISABILITIES ACT 159 RIGHT TO ACCESS TO HEALTH CARE AND HEALTH PROMOTION 160 FOCUS OF REHABILITATION 160 THE REHABILITATION TEAM 161 AREAS OF SPECIALTY PRACTICE 162 ASSESSMENT OF FUNCTIONAL ABILITIES 163
3
Concepts and Challenges in Patient Management
13 Pain Management THE FIFTH VITAL SIGN TYPES OF PAIN 217
214 216
217
Acute Pain 218 Chronic (Nonmalignant) Pain 218 Cancer-Related Pain 218 Pain Classified by Location 218 Pain Classified by Etiology 218
218
Effects of Acute Pain 218 Effects of Chronic Pain 218
PATHOPHYSIOLOGY OF PAIN
220
Pain Transmission 220 Factors Influencing the Pain Response
NURSING ASSESSMENT OF PAIN
223
226
Characteristics of Pain 226 Instruments for Assessing the Perception of Pain Nurse’s Role in Pain Management 230
PAIN MANAGEMENT STRATEGIES
DISABILITY AND SEXUALITY ISSUES 183 FATIGUE 183 HOME AND COMMUNITY-BASED CARE 183 COMPLEMENTARY THERAPIES 184 CONTINUING CARE 184
228
232
Pharmacologic Interventions 232 Routes of Administration 237 Nonpharmacologic Interventions 240
NEUROLOGIC AND NEUROSURGICAL APPROACHES TO PAIN MANAGEMENT 241
12 Health Care of the Older Adult
188
OVERVIEW OF AGING 189
Demographics of Aging 189 Health Costs of Aging 189 Ethical and Legal Issues Affecting the Older Adult Nursing Care of Older Adults 191
Unit
HARMFUL EFFECTS OF PAIN
Nursing Process: The Patient With Self-Care Deficit in Activities of Daily Living 163 Nursing Process: The Patient With Impaired Physical Mobility 165 Nursing Process: The Patient With Impaired Skin Integrity 175 Nursing Process: The Patient With Altered Elimination Patterns 181
Stimulation Procedures 242 Alternative Therapies 243
PROMOTING HOME AND COMMUNITY-BASED CARE 190
NORMAL AGE-RELATED CHANGES AND HEALTH PROMOTION ACTIVITIES 191 Physical Aspects of Aging 191 Psychosocial Aspects of Aging 197 Cognitive Aspects of Aging 198 Environmental Aspects of Aging 198 Pharmacologic Aspects of Aging 201
Depression 204 Delirium 204 The Dementias: Multi-Infarct Dementia and Alzheimer’s Disease 205
137
Genetics and Health Assessment 138 Genetic Counseling and Evaluation Services 140
10 Chronic Illness
203
COMMON MENTAL HEALTH PROBLEMS IN OLDER POPULATIONS 204
APPLICATIONS OF GENETICS IN NURSING PRACTICE ETHICAL ISSUES
xix
Teaching Patients Self-Care Continuing Care 244
EVALUATING PAIN MANAGEMENT STRATEGIES Reassessments
243
243
244
245
14 Fluid and Electrolytes: Balance and Distribution FUNDAMENTAL CONCEPTS
250
Amount and Composition of Body Fluids 250 Regulation of Body Fluid Compartments 251
249
xx
Contents
16 Oncology: Nursing Management in Cancer Care
Routes of Gains and Losses 252 Laboratory Tests for Evaluating Fluid Status 252 Homeostatic Mechanisms 253
FLUID VOLUME DISTURBANCES
256
Fluid Volume Deficit (Hypovolemia) 256 Fluid Volume Excess (Hypervolemia) 260
ELECTROLYTE IMBALANCES
261
DETECTION AND PREVENTION OF CANCER
Purpose 282 Types of IV Solutions
DIAGNOSIS OF CANCER AND RELATED NURSING CONSIDERATIONS 323 Tumor Staging and Grading
MANAGEMENT OF CANCER
Hospice
361
ONCOLOGIC EMERGENCIES
17 End-of-Life Care
361
NURSING AND END-OF-LIFE CARE
282
369 370
The Context for Death and Dying in America Technology and End-of-Life Care 370 Sociocultural Context 371
282
295
298
302
Expected Physiologic Changes When the Patient Is Close to Death 387 The Death Vigil 387 After-Death Care 387 Grief, Mourning, and Bereavement 389
HYPOVOLEMIC SHOCK 304 CARDIOGENIC SHOCK 306 CIRCULATORY SHOCK 309 Septic Shock 309 Neurogenic Shock 311 Anaphylactic Shock 311
312
375
Psychosocial Issues 376 Communication 376 Providing Culturally Sensitive Care at the End of Life 378 Goal Setting in Palliative Care at the End of Life 380 Spiritual Care 380 Hope 382 Managing Physiologic Responses to Illness 382 Palliative Sedation at the End of Life 386
NURSING CARE OF THE PATIENT WHO IS CLOSE TO DEATH 387
303
MULTIPLE ORGAN DYSFUNCTION SYNDROME
SETTINGS FOR END-OF-LIFE CARE: PALLIATIVE CARE PROGRAMS AND HOSPICE 373 NURSING CARE OF THE TERMINALLY ILL PATIENT
Compensatory Stage 299 Progressive Stage 300 Irreversible Stage 301
OVERALL MANAGEMENT STRATEGIES IN SHOCK
370
Palliative Care 373 Hospice Care 374
296
Classification of Shock 296 Normal Cellular Function 296 Pathophysiology 296
Fluid Replacement 302 Vasoactive Medication Therapy Nutritional Support 303
325
CANCER REHABILITATION 358 CARE OF THE PATIENT WITH ADVANCED CANCER 360
15 Shock and Multisystem Failure STAGES OF SHOCK
323
Surgery 325 Radiation Therapy 328 Chemotherapy 329 Bone Marrow Transplantation 343 Hyperthermia 345 Biologic Response Modifiers 345 Photodynamic Therapy 349 Gene Therapy 349 Unproven and Unconventional Therapies 349 Nursing Process: The Patient With Cancer 350
278
SIGNIFICANCE OF SHOCK 296 CONDITIONS PRECIPITATING SHOCK
322
Primary Prevention 322 Secondary Prevention 322
Buffer Systems 278 Acute and Chronic Metabolic Acidosis (Base Bicarbonate Deficit) 278 Acute and Chronic Metabolic Alkalosis (Base Bicarbonate Excess) 279 Acute and Chronic Respiratory Acidosis (Carbonic Acid Excess) 280 Acute and Chronic Respiratory Alkalosis (Carbonic Acid Deficit) 281 Mixed Acid–Base Disorders 281 Compensation 281 Blood Gas Analysis 281
PARENTERAL FLUID THERAPY
316
Proliferative Patterns 316 Characteristics of Malignant Cells 317 Invasion and Metastasis 318 Etiology 320 Role of the Immune System 321
Significance of Sodium 261 Sodium Deficit (Hyponatremia) 263 Sodium Excess (Hypernatremia) 265 Significance of Potassium 266 Potassium Deficit (Hypokalemia) 266 Potassium Excess (Hyperkalemia) 268 Significance of Calcium 270 Calcium Deficit (Hypocalcemia) 270 Calcium Excess (Hypercalcemia) 272 Significance of Magnesium 273 Magnesium Deficit (Hypomagnesemia) 273 Magnesium Excess (Hypermagnesemia) 274 Significance of Phosphorus 275 Phosphorus Deficit (Hypophosphatemia) 275 Phosphorus Excess (Hyperphosphatemia) 276 Significance of Chloride 277 Chloride Deficit (Hypochloremia) 277 Chloride Excess (Hyperchloremia) 277
ACID–BASE DISTURBANCES
315
EPIDEMIOLOGY 316 PATHOPHYSIOLOGY OF THE MALIGNANT PROCESS
COPING WITH DEATH AND DYING: PROFESSIONAL CAREGIVER ISSUES
391
Contents
Unit
4
THE HOSPITALIZED POSTOPERATIVE PATIENT
Perioperative Concepts and Nursing Management
398
PERIOPERATIVE AND PERIANESTHESIA NURSING
399
Preoperative Phase 399 Intraoperative Phase 399 Postoperative Phase 400
Anatomy of the Upper Respiratory Tract 463 Anatomy of the Lower Respiratory Tract: Lungs Function of the Respiratory System 466
ASSESSMENT
409
Preoperative Teaching 409 Preoperative Psychosocial Interventions 412 General Preoperative Nursing Interventions 412 Immediate Preoperative Nursing Interventions 412 Nursing Process: Care of the Patient in the Preoperative Period 414
417
418
The Patient 418 The Circulating Nurse 419 The Scrub Role 419 The Surgeon 419 The Registered Nurse First Assistant 419 The Anesthesiologist and Anesthetist 420
UPPER AIRWAY INFECTIONS
Principles of Surgical Asepsis 421 Health Hazards Associated With the Surgical Environment 422
424
429
Nausea and Vomiting 429 Anaphylaxis 430 Hypoxia and Other Respiratory Complications 430 Hypothermia 431 Malignant Hyperthermia 431 Disseminated Intravascular Coagulopathy 431 Nursing Process: The Patient During Surgery 431
437
Phases of Postanesthesia Care 437 Admitting the Patient to the PACU 437 Nursing Management in the PACU 438
494
495
Rhinitis 495 Viral Rhinitis (Common Cold) 496 Acute Sinusitis 497 Chronic Sinusitis 499 Acute Pharyngitis 500 Chronic Pharyngitis 501 Tonsillitis and Adenoiditis 501 Peritonsillar Abscess 502 Laryngitis 502 Nursing Process: The Patient With Upper Airway Infection 503
423
THE POSTANESTHESIA CARE UNIT
483
Pulmonary Function Tests 483 Arterial Blood Gas Studies 484 Pulse Oximetry 484 Cultures 485 Sputum Studies 485 Imaging Studies 485 Endoscopic Procedures 486 Thoracentesis 488 Biopsy 488
22 Management of Patients With Upper Respiratory Tract Disorders
420
20 Postoperative Nursing Management
464
471
DIAGNOSTIC EVALUATION
19 Intraoperative Nursing Management
POTENTIAL INTRAOPERATIVE COMPLICATIONS
462
463
Health History 471 Physical Assessment of the Upper Respiratory Structures 475 Physical Assessment of the Lower Respiratory Structures and Breathing 476 Physical Assessment of Breathing Ability in the Acutely Ill Patient 482
409
PREOPERATIVE NURSING INTERVENTIONS
Sedation and Anesthesia 423 Methods of Anesthesia Administration
460
ANATOMIC AND PHYSIOLOGIC OVERVIEW
407
The Ambulatory Surgery Patient 408 Elderly Patients 408 Obese Patients 408 Patients With Disabilities 408 Patients Undergoing Emergency Surgery
THE SURGICAL EXPERIENCE
5
21 Assessment of Respiratory Function
Informed Consent 402 Assessment of Health Factors That Affect Patients Preoperatively 403
THE SURGICAL ENVIRONMENT
Unit
Gas Exchange and Respiratory Function
SURGICAL CLASSIFICATIONS 402 PRELIMINARIES TO SURGERY 402
SPECIAL CONSIDERATIONS
442
Receiving the Patient in the Clinical Unit 443 Nursing Management After Surgery 443 Nursing Process: The Hospitalized Patient Recovering From Surgery 444
396
18 Preoperative Nursing Management
THE SURGICAL TEAM
xxi
OBSTRUCTION AND TRAUMA OF THE UPPER RESPIRATORY AIRWAY 505
436
Obstruction During Sleep 505 Epistaxis (Nosebleed) 506 Nasal Obstruction 507 Fractures of the Nose 507 Laryngeal Obstruction 507
CANCER OF THE LARYNX
508
Nursing Process: The Patient Undergoing Laryngectomy
512
Contents
xxii
23 Management of Patients With Chest and Lower Respiratory Tract Disorders 518 ATELECTASIS 519 RESPIRATORY INFECTIONS
521
Acute Tracheobronchitis 521 Pneumonia 522 Nursing Process: The Patient With Pneumonia 531 Pulmonary Tuberculosis 534 Nursing Process: The Patient With Tuberculosis 538 Lung Abscess 540
PLEURAL CONDITIONS
THE PATIENT UNDERGOING THORACIC SURGERY
Unit
Silicosis 555 Asbestosis 555 Coal Workers’ Pneumoconiosis 555
559 562
24 Management of Patients With Chronic Obstructive Pulmonary Disorders 570 CHRONIC OBSTRUCTIVE PULMONARY DISEASE Nursing Process: The Patient With COPD
571
580
ANATOMIC AND PHYSIOLOGIC OVERVIEW
Status Asthmaticus 597
597
601 602
Oxygen Therapy 602 Intermittent Positive-Pressure Breathing 607 Mini-nebulizer Therapy 607 Incentive Spirometry (Sustained Maximal Inspiration) Chest Physiotherapy 608
AIRWAY MANAGEMENT
608
612
Emergency Management of Upper Airway Obstruction Endotracheal Intubation 612 Tracheostomy 614
MECHANICAL VENTILATION
615
Indications for Mechanical Ventilation
615
653
653 654
668
Laboratory Tests 668 Chest X-ray and Fluoroscopy 670 Electrocardiography 670 Cardiac Stress Testing 671 Echocardiography 672 Radionuclide Imaging 673 Cardiac Catheterization 675 Angiography 675 Electrophysiologic Testing 676 Hemodynamic Monitoring 677
27 Management of Patients With Dysrhythmias and DYSRHYTHMIAS
NONINVASIVE RESPIRATORY THERAPIES
647
Anatomy of the Heart 647 Function of the Heart: Conduction System 649 Gender Differences in Cardiac Structure and Function
Conduction Problems
583
25 Respiratory Care Modalities
644
26 Assessment of Cardiovascular Function 646
DIAGNOSTIC EVALUATION
556
565
CYSTIC FIBROSIS
Cardiovascular, Circulatory, and Hematologic Function
Health History and Clinical Manifestations Physical Assessment 661
556
Blunt Trauma 560 Penetrating Trauma: Gunshot and Stab Wounds Pneumothorax 563 Cardiac Tamponade 564 Subcutaneous Emphysema 565
BRONCHIECTASIS ASTHMA 589
6
ASSESSMENT
Lung Cancer (Bronchogenic Carcinoma) Tumors of the Mediastinum 559
ASPIRATION
635
542
PULMONARY EDEMA 544 ACUTE RESPIRATORY FAILURE 545 ACUTE RESPIRATORY DISTRESS SYNDROME 546 PULMONARY HYPERTENSION 548 PULMONARY HEART DISEASE (COR PULMONALE) 549 PULMONARY EMBOLISM 550 SARCOIDOSIS 554 OCCUPATIONAL LUNG DISEASES: PNEUMOCONIOSES 554
CHEST TRAUMA
628
Preoperative Management 628 Preoperative Nursing Management 628 Postoperative Management 630 Nursing Process: The Patient Undergoing Thoracic Surgery
Pleurisy 542 Pleural Effusion 542 Empyema 543
CHEST TUMORS
Classification of Ventilators 615 Adjusting the Ventilator 619 Assessing the Equipment 619 Problems With Mechanical Ventilation 620 Nursing Process: The Patient on a Ventilator 622 Weaning the Patient From the Ventilator 624
612
682
683
Normal Electrical Conduction 683 Interpretation of the Electrocardiogram 684 Analyzing the Electrocardiogram Rhythm Strip 687 Nursing Process: The Patient With a Dysrhythmia 698
ADJUNCTIVE MODALITIES AND MANAGEMENT Pacemaker Therapy 700 Nursing Process: The Patient With a Pacemaker Cardioversion and Defibrillation 705 Electrophysiologic Studies 708 Cardiac Conduction Surgery 709
28 Management of Patients With Coronary Vascular Disorders CORONARY ARTERY DISEASE Coronary Atherosclerosis Angina Pectoris 719
713
713
699 703
712
Contents Nursing Process: The Patient With Angina Pectoris 723 Myocardial Infarction 725 Nursing Process: The Patient With Myocardial Infarction 729
INVASIVE CORONARY ARTERY PROCEDURES
733
Invasive Interventional Procedures 733 Surgical Procedures 737 Nursing Process: The Patient Awaiting Cardiac Surgery Intraoperative Nursing Management 748 Nursing Process: The Patient Who Has Had Cardiac Surgery 748
739
29 Management of Patients With Structural, Infectious, and 763
764
Mitral Valve Prolapse 764 Mitral Regurgitation 766 Mitral Stenosis 767 Aortic Regurgitation 767 Aortic Stenosis 767 Valvular Heart Disorders: Nursing Management
768
VALVE REPAIR AND REPLACEMENT PROCEDURES Valvuloplasty 768 Valve Replacement 770 Valvuloplasty and Replacement: Nursing Management
768 772
Nursing Process: The Patient With Cardiomyopathy
CARDIAC TUMOR AND TRAUMA SURGERY
820
821
Doppler Ultrasound Flow Studies Exercise Testing 822 Duplex Ultrasonography 822 Computed Tomography 823 Angiography 823 Air Plethysmography 824 Contrast Phlebography 824 Lymphangiography 824 Lymphoscintigraphy 824
821
824
Arteriosclerosis and Atherosclerosis 824 Nursing Process: The Patient Who Has Peripheral Arterial Insufficiency of the Extremities 826 Peripheral Arterial Occlusive Disease 830 Thromboangiitis Obliterans (Buerger’s Disease) 834 Aortitis 835 Aortoiliac Disease 835 Aortic Aneurysm 835 Dissecting Aorta 839 Other Aneurysms 839 Arterial Embolism and Arterial Thrombosis 840 Raynaud’s Disease 841
INFECTIOUS DISEASES OF THE HEART
776
778
778
Rheumatic Endocarditis 778 Infective Endocarditis 780 Myocarditis 782 Pericarditis 783 Nursing Process: The Patient With Pericarditis 784
30 Management of Patients With Complications From Heart Disease
CELLULITIS 850 MANAGEMENT OF LYMPHATIC DISORDERS
787
HYPERTENSIVE CRISES
806
33 Assessment and Management of Patients With Hematologic Disorders
809
ANATOMIC AND PHYSIOLOGIC OVERVIEW
31 Assessment and Management of Patients With Vascular Disorders and Anatomy of the Vascular System 816 Function of the Vascular System 817 Pathophysiology of the Vascular System
816
858
865
Hypertensive Emergency 865 Hypertensive Urgency 865
801
Problems of Peripheral Circulation
854
Nursing Process: The Patient With Hypertension
HEART FAILURE 789
ANATOMIC AND PHYSIOLOGIC OVERVIEW
32 Assessment and Management of Patients With Hypertension HYPERTENSION DEFINED 855 PRIMARY HYPERTENSION 855
Noninvasive Assessment of Cardiac Hemodynamics 789 Invasive Assessment of Cardiac Hemodynamics 789
Cardiogenic Shock 806 Thromboembolism 808 Pericardial Effusion and Cardiac Tamponade Myocardial Rupture 810 Cardiac Arrest 810
851
Lymphangitis and Lymphadenitis 851 Lymphedema and Elephantiasis 851
788
Chronic Heart Failure 789 Nursing Process: The Patient With Heart Failure Acute Heart Failure (Pulmonary Edema) 805
842
Venous Thrombosis, Deep Vein Thrombosis (DVT), Thrombophlebitis, and Phlebothrombosis 842 Chronic Venous Insufficiency 845 Leg Ulcers 846 Nursing Process: The Patient Who Has Leg Ulcers 848 Varicose Veins 849
Tumor Excision 778 Trauma Repair 778
OTHER COMPLICATIONS
DIAGNOSTIC EVALUATION
MANAGEMENT OF VENOUS DISORDERS
SEPTAL REPAIR 772 CARDIOMYOPATHIES 772
CARDIAC HEMODYNAMICS
820
Health History and Clinical Manifestations
MANAGEMENT OF ARTERIAL DISORDERS
Inflammatory Cardiac Disorders ACQUIRED VALVULAR DISORDERS
ASSESSMENT
xxiii
815
Blood 869 Bone Marrow 869 Blood Cells 869 Plasma and Plasma Proteins 873 Reticuloendothelial System 874 Hemostasis 874 Pathophysiology of the Hematologic System
868
875
MANAGEMENT OF HEMATOLOGIC DISORDERS 819
Anemia 877 Nursing Process: The Patient With Anemia
879
877
867
xxiv
Contents HYPOPROLIFERATIVE ANEMIAS HEMOLYTIC ANEMIAS 886
881
Unit
Sickle Cell Anemia 886 Nursing Process: The Patient With Sickle Cell Crisis 889 Thalassemia 891 Glucose-6-Phosphate Dehydrogenase Deficiency 891 Hereditary Spherocytosis 892 Immune Hemolytic Anemia 892 Hereditary Hemochromatosis 893
THE POLYCYTHEMIAS
Digestive and Gastrointestinal Function
ASSESSMENT
DIAGNOSTIC EVALUATION
907
909
956
35 Management of Patients With Oral and Esophageal Disorders
Primary Thrombocythemia 910 Secondary Thrombocytosis 911 Thrombocytopenia 911 Idiopathic Thrombocytopenic Purpura (ITP) Platelet Defects 913 Hemophilia 913 Von Willebrand’s Disease 915
912
DISORDERS OF THE TEETH
915
DISORDERS OF THE JAW
Liver Disease 915 Vitamin K Deficiency 915 Complications of Anticoagulant Therapy 916 Disseminated Intravascular Coagulation (DIC) 916 Nursing Process: The Patient With Disseminated Intravascular Coagulation (DIC) 916 Thrombotic Disorders 919
Parotitis 963 Sialadenitis 963 Salivary Calculus (Sialolithiasis) Neoplasms 964
CANCER OF THE ORAL CAVITY
963
964
Nursing Process: The Patient With Conditions of the Oral Cavity 965
968
Nursing Process: The Patient Undergoing a Neck Dissection 969
923
PROCURING BLOOD AND BLOOD PRODUCTS
962
DISORDERS OF THE SALIVARY GLANDS
NECK DISSECTION
DISORDERS OF THE ESOPHAGUS 924
926
928
Diseases Transmitted by Blood Transfusion 930 Complications of Long-Term Transfusion Therapy 930 Nursing Management for Transfusion Reactions 930 Pharmacologic Alternatives to Blood Transfusions 931 Peripheral Blood Stem Cell Transplantation (PBSCT) and Bone Marrow Transplantation (BMT) 931
961
962
Temporomandibular Disorders
922
958
959
Dental Plaque and Caries 959 Dentoalveolar Abscess or Periapical Abscess Malocclusion 962
ACQUIRED COAGULATION DISORDERS
TRANSFUSION COMPLICATIONS
947
PATHOPHYSIOLOGIC AND PSYCHOLOGICAL CONSIDERATIONS
THERAPIES FOR BLOOD DISORDERS
945
Stool Tests 947 Breath Tests 948 Abdominal Ultrasonography 948 DNA Testing 949 Imaging Studies 949 Endoscopic Procedures 951 Manometry and Electrophysiologic Studies 954 Gastric Analysis, Gastric Acid Stimulation Test, and pH Monitoring 955 Laparoscopy (Peritoneoscopy) 955
906
Blood Donation 924 Complications of Blood Donation Blood Processing 926 Transfusion 926
945
Health History and Clinical Manifestations Physical Assessment 946
Acute Myeloid Leukemia 897 Chronic Myeloid Leukemia 900 Acute Lymphocytic Leukemia 900 Chronic Lymphocytic Leukemia 901 Nursing Process: The Patient With Acute Leukemia 902 Agnogenic Myeloid Metaplasia (AMM) 905
Splenectomy 922 Therapeutic Apheresis 923 Therapeutic Phlebotomy 923 Blood and Blood Component Therapy Special Preparations 923
941
Anatomy of the Gastrointestinal Tract 941 Function of the Digestive System 941
LEUKOPENIA AND NEUTROPENIA 895 LEUKOCYTOSIS AND THE LEUKEMIAS 896
BLEEDING DISORDERS
940
ANATOMIC AND PHYSIOLOGIC OVERVIEW
894
Hodgkin’s Disease 906 Non-Hodgkin’s Lymphomas Multiple Myeloma 908
938
34 Assessment of Digestive and Gastrointestinal Function
Polycythemia Vera 894 Secondary Polycythemia 895
THE LYMPHOMAS
7
972
Dysphagia 972 Achalasia 972 Diffuse Spasm 975 Hiatal Hernia 977 Diverticulum 977 Perforation 978 Foreign Bodies 978 Chemical Burns 978 Gastroesophageal Reflux Disease 979 Barrett’s Esophagus 979 Benign Tumors of the Esophagus 979 Cancer of the Esophagus 979 Nursing Process: The Patient With a Condition of the Esophagus 981
963
Contents
36 Gastrointestinal Intubation and Special Nutritional Modalities
INTESTINAL OBSTRUCTION
984
DISEASES OF THE ANORECTUM 1066 Anorectal Abscess 1066 Anal Fistula 1066 Anal Fissure 1066 Hemorrhoids 1066 Sexually Transmitted Anorectal Diseases Pilonidal Sinus or Cyst 1067 Nursing Process: The Patient With an Anorectal Condition 1068
TUBE FEEDINGS WITH NASOGASTRIC AND NASOENTERIC DEVICES 992 Osmosis and Osmolality 992 Tube Feeding Formulas 992 Tube Feeding Administration Methods 993 Nursing Process: The Patient Receiving a Tube Feeding 993
GASTROSTOMY
998
Nursing Process: The Patient With a Gastrostomy
999
Unit
PARENTERAL NUTRITION 1001 Establishing Positive Nitrogen Balance 1001 Clinical Indications 1002 Formulas 1002 Initiating Therapy 1002 Administration Methods 1002 Discontinuing Parenteral Nutrition 1004 Nursing Process: The Patient Receiving Parenteral Nutrition 1004
1010
1017
1077
Health History 1077 Physical Examination 1078
HEPATIC DYSFUNCTION 1023
38 Management of Patients With Intestinal and Rectal Disorders
1028
ABNORMALITIES OF FECAL ELIMINATION 1029 Constipation 1029 Diarrhea 1030 Fecal Incontinence 1032 Irritable Bowel Syndrome 1033 Conditions of Malabsorption 1034
ACUTE INFLAMMATORY INTESTINAL DISORDERS Appendicitis 1034 Diverticular Disease 1037 Nursing Process: The Patient With Diverticulitis 1038 Peritonitis 1039
1078
1081
Jaundice 1081 Portal Hypertension 1082 Ascites 1082 Esophageal Varices 1085 Hepatic Encephalopathy and Coma 1090 Other Manifestations of Liver Dysfunction 1093
1025
Regional Enteritis (Crohn’s Disease) 1041 Ulcerative Colitis 1042 Nursing Process: Management of the Patient With Inflammatory Bowel Disease 1044 Nursing Management of the Patient Requiring an Ileostomy 1047
1075
Liver Function Tests 1078 Liver Biopsy 1078 Other Diagnostic Tests 1081
Nursing Process: The Patient Undergoing Gastric Surgery 1025
INFLAMMATORY BOWEL DISEASE 1040
ASSESSMENT
DIAGNOSTIC EVALUATION
MORBID OBESITY 1021 GASTRIC CANCER 1022 GASTRIC SURGERY
1074
Anatomy of the Liver 1075 Functions of the Liver 1076
1015
Nursing Process: The Patient With Gastric Cancer
1072
ANATOMIC AND PHYSIOLOGIC OVERVIEW
1011
Nursing Process: The Patient With Ulcer Disease
8
39 Assessment and Management of Patients With Hepatic Disorders
Nursing Process: The Patient With Gastritis 1011
GASTRIC AND DUODENAL ULCERS
1067
Metabolic and Endocrine Function
37 Management of Patients With Gastric and Duodenal Disorders GASTRITIS
1054
Small Bowel Obstruction 1055 Large Bowel Obstruction 1056 Colorectal Cancer 1056 Nursing Process: The Patient With Colorectal Cancer 1058 Polyps of the Colon and Rectum 1065
GASTROINTESTINAL INTUBATION 985 Short Tubes 985 Medium Tubes 986 Long Tubes 986 Nursing Management of Patients Undergoing Nasogastric or Nasoenteric Intubation 987
xxv
1034
MANAGEMENT OF PATIENTS WITH VIRAL HEPATIC DISORDERS 1093 Viral Hepatitis 1093 Hepatitis A Virus (HAV) 1094 Hepatitis B Virus (HBV) 1097 Hepatitis C Virus (HCV) 1099 Hepatitis D Virus 1100 Hepatitis E Virus 1100 Hepatitis G (HGV) and GB Virus-C
1100
MANAGEMENT OF PATIENTS WITH NONVIRAL HEPATIC DISORDERS 1100 Toxic Hepatitis 1100 Drug-Induced Hepatitis 1100 Fulminant Hepatic Failure 1101 Hepatic Cirrhosis 1101 Nursing Process: The Patient With Hepatic Cirrhosis 1103
CANCER OF THE LIVER
1113
Primary Liver Tumors 1113 Liver Metastases 1113
xxvi
Contents
42 Assessment and Management of Patients With Endocrine Disorders
LIVER TRANSPLANTATION 1115 Surgical Procedure 1116 Complications 1117
LIVER ABSCESSES
1118
ANATOMIC AND PHYSIOLOGIC OVERVIEW
40 Assessment and Management of Patients With Biliary Disorders ANATOMIC AND PHYSIOLOGIC OVERVIEW
1123
1124
DISORDERS OF THE GALLBLADDER
1126
Thyroid Function and Dysfunction 1212 Abnormal Thyroid Function 1215 Hypothyroidism 1215 Hyperthyroidism 1221 Nursing Process: The Patient With Hyperthyroidism Thyroiditis 1226 Thyroid Tumors 1226 Endemic (Iodine-Deficient) Goiter 1227 Nodular Goiter 1227 Thyroid Cancer 1228
1145
1149
1151
NURSING MANAGEMENT
MANAGEMENT OF PATIENTS WITH PARATHYROID DISORDERS 1231
MANAGEMENT OF PATIENTS WITH ADRENAL DISORDERS 1234 Adrenal Function 1234 Pheochromocytoma 1235 Adrenocortical Insufficiency (Addison’s Disease) 1237 Cushing’s Syndrome 1239 Nursing Process: The Patient With Cushing’s Syndrome 1240
1155
Nutritional Management 1156 Exercise 1160 Monitoring: Glucose Levels and Ketones Pharmacologic Therapy 1163
1161
CORTICOSTEROID THERAPY
1171
Education 1171 Developing a Diabetic Teaching Plan Implementing the Plan 1173
1178
Hypoglycemia (Insulin Reactions) 1178 Diabetic Ketoacidosis 1180 Hyperglycemic Hyperosmolar Nonketotic Syndrome Nursing Process: The Patient Newly Diagnosed With Diabetes Mellitus 1184
LONG-TERM COMPLICATIONS OF DIABETES
1183
1188
Macrovascular Complications 1188 Microvascular Complications and Diabetic Retinopathy Nephropathy 1191 Diabetic Neuropathies 1192 Foot and Leg Problems 1194
SPECIAL ISSUES IN DIABETES CARE
1243
Side Effects 1244 Therapeutic Uses of Corticosteroids Dosage 1244 Tapering 1245
1172
ACUTE COMPLICATIONS OF DIABETES
1224
Parathyroid Function 1231 Hyperparathyroidism 1231 Hypoparathyroidism 1232
Overview 1151 Physiology and Pathophysiology of Diabetes 1151 Type 1 Diabetes 1153 Type 2 Diabetes 1153 Gestational Diabetes 1154
DIABETES MANAGEMENT
1206
MANAGEMENT OF PATIENTS WITH THYROID DISORDERS 1212
41 Assessment and Management of Patients With Diabetes Mellitus CLASSIFICATION OF DIABETES
1206
Pituitary Function and Dysfunction 1209 Diabetes Insipidus 1211 Syndrome of Inappropriate Antidiuretic Hormone Secretion 1212
1135
Acute Pancreatitis 1135 Nursing Process: The Patient With Acute Pancreatitis 1138 Chronic Pancreatitis 1142 Pancreatic Cysts 1143 Cancer of the Pancreas 1144 Tumors of the Head of the Pancreas Pancreatic Islet Tumors 1147 Hyperinsulinism 1147 Ulcerogenic Tumors 1147
ASSESSMENT
DIAGNOSTIC EVALUATION 1207 MANAGEMENT OF PATIENTS WITH PITUITARY DISORDERS 1209
Cholecystitis 1126 Cholelithiasis 1126 Nursing Process: The Patient Undergoing Surgery for Gallbladder Disease 1133
DISORDERS OF THE PANCREAS
1205
Glands of the Endocrine System 1205 Function and Regulation of Hormones 1206 Classification and Action of Hormones 1206 Health History and Clinical Manifestations Physical Assessment 1207
Anatomy of the Gallbladder 1124 Function of the Gallbladder 1124 The Pancreas 1124
1204
1195
The Patient With Diabetes Undergoing Surgery 1195 Management of Hospitalized Diabetic Patients 1196 Nursing Process: The Patient With Diabetes as a Secondary Diagnosis 1198
1189
Unit
1244
9
Urinary Tract Function
1248
43 Assessment of Renal and Urinary Tract Function ANATOMIC AND PHYSIOLOGIC OVERVIEW
1250 1251
Anatomy of the Upper and Lower Urinary Tracts 1251 Physiology of the Upper and Lower Urinary Tracts 1253
ASSESSMENT
1257
Health History 1257 Physical Examination 1259
Contents DIAGNOSTIC EVALUATION 1261
URINARY TRACT CANCERS
Urinalysis and Urine Culture 1261 Renal Function Tests 1262 X-Ray Films and Other Imaging Modalities 1262 Urologic Endoscopic Procedures 1265 Biopsy 1266 Urodynamic Tests 1267
NURSING IMPLICATIONS
URINARY DIVERSIONS
OTHER URINARY TRACT DISORDERS
1268
Unit
Tract Dysfunction
1271
FLUID AND ELECTROLYTE IMBALANCES IN RENAL DISORDERS 1272 DYSFUNCTIONAL VOIDING PATTERNS 1273
ASSESSMENT
1381
MANAGEMENT OF NORMAL AND ALTERED FEMALE PHYSIOLOGIC PROCESSES 1385
1309 1310
Lower Urinary Tract Infections 1310 Nursing Process: The Patient With Lower Urinary Tract Infection 1314 Upper Urinary Tract Infection: Acute Pyelonephritis 1315 Upper Urinary Tract Infection: Chronic Pyelonephritis 1316
1317
RENAL FAILURE 1321 Acute Renal Failure 1321 Chronic Renal Failure (End-Stage Renal Disease)
Menstruation 1385 Perimenopause 1386 Menopause 1387 Premenstrual Syndrome 1389 Dysmenorrhea 1391 Amenorrhea 1391 Abnormal Uterine Bleeding 1392
MANAGEMENT OF NORMAL AND ALTERED FEMALE REPRODUCTIVE FUNCTION 1392 Dyspareunia 1392 Contraception 1392 Abortion 1398 Ectopic Pregnancy 1403 Nursing Process: The Patient With an Ectopic Pregnancy 1405
Acute Glomerulonephritis 1317 Chronic Glomerulonephritis 1319 Nephrotic Syndrome 1320
1326
KIDNEY TRANSPLANTATION 1334 Preoperative Management 1335 Postoperative Management 1335
1337
47 Management of Patients With Female Reproductive Disorders VULVOVAGINAL INFECTIONS
Nursing Process: The Patient With Kidney Stones
1342
1372
Cytologic Test for Cancer (Pap Smear) 1381 Colposcopy and Cervical Biopsy 1381 Cryotherapy and Laser Therapy 1381 Cone Biopsy and LEEP 1382 Endometrial (Aspiration) Biopsy 1382 Dilation and Curettage 1384 Endoscopic Examinations 1384 Other Diagnostic Procedures 1385
45 Management of Patients With Urinary Disorders
Renal Trauma 1343 Ureteral Trauma 1343 Bladder Trauma 1343 Urethral Trauma 1343
1368
1372
DIAGNOSTIC EVALUATION
1298
GENITOURINARY TRAUMA
1366
Health History and Clinical Manifestations Physical Assessment 1377
Preoperative Considerations 1298 Perioperative Concerns 1299 Postoperative Management 1299 Nursing Process: The Patient Undergoing Kidney Surgery 1300
UROLITHIASIS
Reproductive Function
Anatomy of the Female Reproductive System 1370 Function of the Female Reproductive System 1370
1285
PRIMARY GLOMERULAR DISEASES
10
ROLE OF NURSES IN WOMEN’S HEALTH 1369 ANATOMIC AND PHYSIOLOGIC OVERVIEW 1370
Hemodialysis 1285 Continuous Renal Replacement Therapies 1290 Peritoneal Dialysis 1291 Special Considerations: Care of the Hospitalized Dialysis Patient 1297
INFECTIONS OF THE URINARY TRACT
1357
46 Assessment and Management of Female Physiologic Processes
Congenital Voiding Dysfunction 1274 Adult Voiding Dysfunction 1274 Urinary Incontinence 1275 Urinary Retention 1278 Neurogenic Bladder 1280
KIDNEY SURGERY
1347
Cutaneous Urinary Diversions 1348 Continent Urinary Diversions 1352 Other Urinary Diversion Procedures 1353 Nursing Process: The Patient Undergoing Urinary Diversion Surgery 1353
44 Management of Patients With Upper or Lower Urinary
DIALYSIS
1344
Cancer of the Kidney 1344 Cancer of the Bladder 1346
1268
Nursing Diagnosis 1268 Planning, Implementation, and Evaluation
xxvii
1341
1410
1411
Candidiasis 1412 Seminal Plasma Protein Allergy 1413 Bacterial Vaginosis 1413 Trichomoniasis 1413 Nursing Process: The Patient With a Vulvovaginal Infection Human Papillomavirus 1415
1414
xxviii
Contents Herpesvirus Type 2 Infection (Herpes Genitalis, Herpes Simplex Virus) 1416 Nursing Process: The Patient With a Genital Herpesvirus Infection 1416 Toxic Shock Syndrome 1417 Endocervicitis and Cervicitis 1419 Chlamydia and Gonorrhea 1419 Pelvic Infection (Pelvic Inflammatory Disease) 1420 Human Immunodeficiency Virus Infection and Acquired Immunodeficiency Syndrome 1421
STRUCTURAL DISORDERS
Invasive Carcinoma
1422
Fistulas of the Vagina 1422 Pelvic Organ Prolapse: Cystocele, Rectocele, Enterocele Uterine Prolapse 1423
1422
DISEASES OF THE MALE BREAST
49 Assessment and Management of Problems Related to Male Reproductive Processes
ASSESSMENT
DIAGNOSTIC EVALUATION
48 Assessment and Management of Patients With Breast Disorders 1446
Health History and Clinical Manifestations 1447 Physical Assessment: Female Breast 1447 Physical Assessment: Male Breast 1450
DIAGNOSTIC EVALUATION 1450 Breast Self-Examination 1450 Mammography 1452 Ultrasonography 1452 Magnetic Resonance Imaging 1453 Procedures for Tissue Analysis 1453
NURSING CARE OF THE PATIENT UNDERGOING A BREAST BIOPSY 1453 OVERVIEW OF BREAST CONDITIONS AND DISEASES 1454 CONDITIONS AFFECTING THE NIPPLE 1454 BREAST INFECTIONS 1454 BENIGN CONDITIONS OF THE BREAST 1455
Carcinoma in Situ (Noninvasive)
1487
Health History and Clinical Manifestations Physical Assessment 1488
Side Effects of Radiation Therapy 1439 Methods of Radiation Therapy 1440
1445
1456
1456
1456
1487
1489
Prostate-Specific Antigen Test 1489 Ultrasonography 1489 Prostate Fluid or Tissue Analysis 1489 Tests of Male Sexual Function 1489
DISORDERS OF MALE SEXUAL FUNCTION
1489
Erectile Dysfunction 1489 Ejaculation Problems 1491
INFECTIONS OF THE MALE GENITOURINARY TRACT CONDITIONS OF THE PROSTATE 1494 Prostatitis 1494 Benign Prostatic Hyperplasia (Enlarged Prostate) 1494 Cancer of the Prostate 1495 The Patient Undergoing Prostate Surgery 1502 Nursing Process: The Patient Undergoing Prostatectomy 1503
CONDITIONS AFFECTING THE TESTES AND ADJACENT STRUCTURES 1508 Undescended Testis (Cryptorchidism) Orchitis 1508 Epididymitis 1508 Testicular Cancer 1509 Hydrocele 1511 Varicocele 1511 Vasectomy 1511
CONDITIONS AFFECTING THE PENIS
MALIGNANT CONDITIONS OF THE BREAST
1486
Testicular Development 1486 Glandular Function 1487
1439
Fibrocystic Breast Changes 1455 Fibroadenomas 1456 Other Benign Conditions 1456 Benign Proliferative Breast Disease
1485
ANATOMIC AND PHYSIOLOGIC OVERVIEW
Preoperative Management 1437 Postoperative Management 1437 Nursing Process: The Patient Undergoing a Hysterectomy 1437
ANATOMIC AND PHYSIOLOGIC OVERVIEW ASSESSMENT 1447
1479
1481
Gynecomastia 1481 Male Breast Cancer 1481
1437
RADIATION THERAPY
1478
Reduction Mammoplasty 1479 Augmentation Mammoplasty 1479 Reconstructive Procedures After Mastectomy
Cancer of the Cervix 1429 Pregnancy-Related Neoplasm 1431 Cancer of the Uterus (Endometrium) 1432 Cancer of the Vulva 1432 Nursing Process: The Patient Undergoing Vulvar Surgery 1433 Cancer of the Vagina 1435 Cancer of the Fallopian Tubes 1435 Cancer of the Ovary 1435
1457
Reconstructive Surgery 1467 Prosthetics 1467 Quality of Life and Breast Cancer 1468 Pregnancy and Breast Cancer 1468 Nursing Process: The Patient With Breast Cancer 1469 Recurrent Breast Cancer 1475
RECONSTRUCTIVE BREAST SURGERY
BENIGN DISORDERS 1425 MALIGNANT CONDITIONS 1429
HYSTERECTOMY
1457
CURRENT RESEARCH IN BREAST CANCER PROPHYLACTIC MASTECTOMY 1458 BREAST CANCER 1458 SPECIAL ISSUES IN BREAST CANCER MANAGEMENT 1467
Hypospadias and Epispadias Phimosis 1512 Cancer of the Penis 1512 Priapism 1512
1512
1508
1512
1491
Contents Peyronie’s Disease 1513 Urethral Stricture 1513 Circumcision 1513
Unit
11
Immunologic Function ANATOMIC AND PHYSIOLOGIC OVERVIEW
1520 1521
1530
RHEUMATIC DISEASES
Genetic Engineering 1530 Stem Cells 1530 Immunoregulation 1531
ASSESSMENT
NEW APPROACHES TO TREATMENT OF ALLERGIC DISEASES 1603
54 Assessment and Management of Patients With Rheumatic Disorders
Anatomy of the Immune System 1521 Immune Function: Defenses and Responses 1521
ADVANCES IN IMMUNOLOGY
Nursing Process: The Patient With Allergic Rhinitis 1595 Contact Dermatitis 1597 Atopic Dermatitis 1597 Dermatitis Medicamentosa (Drug Reactions) 1598 Urticaria and Angioneurotic Edema 1599 Hereditary Angioedema 1599 Food Allergy 1599 Serum Sickness 1600 Latex Allergy 1600
1518
50 Assessment of Immune Function
1531
PRIMARY IMMUNODEFICIENCIES
1537
DEGENERATIVE JOINT DISEASE (OSTEOARTHRITIS) SPONDYLOARTHROPATHIES 1628 Ankylosing Spondylitis 1629 Reactive Arthritis (Reiter’s Syndrome) Psoriatic Arthritis 1629
1538
Phagocytic Dysfunction 1538 B-Cell Deficiencies 1540 T-Cell Deficiencies 1541 Combined B-Cell and T-Cell Deficiencies 1542 Deficiencies of the Complement System 1542
Gout
52 Management of Patients With HIV Infection and AIDS Nursing Process: The Patient With AIDS
1547
1576
ALLERGIC REACTION: PHYSIOLOGIC OVERVIEW Function and Production of Immunoglobulins Function of Antigens 1582 Function of Chemical Mediators 1582 Hypersensitivity 1584
1581
1586
Health History and Clinical Manifestations
1586
DIAGNOSTIC EVALUATION 1586 Complete Blood Count With Differential 1586 Eosinophil Count 1586 Total Serum Immunoglobulin E Levels 1586 Skin Tests 1586 Provocative Testing 1589 Radioallergosorbent Test 1589
1589
Unit
1565
53 Assessment and Management of Patients With Allergic Disorders
1629
1630
FIBROMYALGIA 1631 ARTHRITIS ASSOCIATED WITH INFECTIOUS ORGANISMS 1631 NEOPLASMS AND NEUROVASCULAR, BONE, AND EXTRA-ARTICULAR DISORDERS 1631 MISCELLANEOUS DISORDERS 1632
1548
EMOTIONAL AND ETHICAL CONCERNS
1627
1629
METABOLIC AND ENDOCRINE DISEASES ASSOCIATED WITH RHEUMATIC DISORDERS
SECONDARY IMMUNODEFICIENCIES 1543 NURSING MANAGEMENT FOR PATIENTS WITH IMMUNODEFICIENCIES 1543
Anaphylaxis 1589 Allergic Rhinitis 1591
1612
1620
Rheumatoid Arthritis 1621 Systemic Lupus Erythematosus 1623 Scleroderma 1625 Polymyositis 1626 Polymyalgia Rheumatica 1626
51 Management of Patients With Immunodeficiency
ALLERGIC DISORDERS
1606
DIFFUSE CONNECTIVE TISSUE DISEASES
DIAGNOSTIC EVALUATION 1535
ASSESSMENT
1605
Nursing Process: The Patient With a Rheumatic Disease
Health History 1531 Physical Examination 1535
HIV INFECTION AND AIDS
xxix
1580 1581
12
Integumentary Function
1636
55 Assessment of Integumentary Function
1638
ANATOMIC AND PHYSIOLOGIC OVERVIEW
1639
Anatomy of the Skin, Hair, Nails, and Glands of the Skin 1639 Functions of the Skin 1642
ASSESSMENT
1644
Health History and Clinical Manifestations Physical Assessment 1645
DIAGNOSTIC EVALUATION
1652
Skin Biopsy 1652 Immunofluorescence 1652 Patch Testing 1652 Skin Scrapings 1652 Tzanck Smear 1652 Wood’s Light Examination 1652 Clinical Photographs 1653
1644
xxx
Contents
56 Management of Patients With Dermatologic Problems
1654
SKIN CARE FOR PATIENTS WITH SKIN CONDITIONS 1655 WOUND CARE FOR SKIN CONDITIONS PRURITUS 1660 SECRETORY DISORDERS 1665
1655
BURN CARE IN THE HOME
FUNGAL (MYCOTIC) INFECTIONS 1672 PARASITIC SKIN INFESTATION 1674 CONTACT DERMATITIS 1676 NONINFECTIOUS INFLAMMATORY DERMATOSES 1676
Unit
1739
13
Sensorineural Function
1744
58 Assessment and Management of Patients With Eye and Vision Disorders 1746
Psoriasis 1676 Nursing Process: Care of the Patient With Psoriasis 1679 Exfoliative Dermatitis 1681
ANATOMIC AND PHYSIOLOGIC OVERVIEW ASSESSMENT 1750
1681
Pemphigus 1681 Bullous Pemphigoid 1682 Dermatitis Herpetiformis 1682 Herpes Gestationis 1682 Nursing Process: Care of the Patient With Blistering Diseases 1683 Toxic Epidermal Necrolysis and Stevens-Johnson Syndrome 1684 Nursing Process: Care of the Patient With Toxic Epidermal Necrolysis 1685
Ocular Examination
Basal Cell and Squamous Cell Carcinoma Malignant Melanoma 1690 Nursing Process: Care of the Patient With Malignant Melanoma 1691 Metastatic Skin Tumors 1694
Refractive Errors 1753 Low Vision and Blindness
GLAUCOMA 1757 CATARACTS 1761 CORNEAL DISORDERS
1751 1753
1764
Corneal Dystrophies 1764 Keratoconus 1765 Corneal Surgeries 1765 Refractive Surgeries 1766
RETINAL DISORDERS
1767
Retinal Detachment 1767 Retinal Vascular Disorders 1768 Macular Degeneration 1769
1688
ORBITAL AND OCULAR TRAUMA 1771 INFECTIOUS AND INFLAMMATORY CONDITIONS
1694
ORBITAL AND OCULAR TUMORS
1778
Benign Tumors 1778 Malignant Tumors 1778
1695
Wound Coverage: Grafts and Flaps 1695 Chemical Face Peeling 1697 Dermabrasion 1697 Facial Reconstructive Surgery 1697 Nursing Process: Care of the Patient With Facial Reconstruction 1698 Face Lift 1700
LASER TREATMENT OF CUTANEOUS LESIONS
1774
Dry Eye Syndrome 1774 Conjunctivitis 1775 Uveitis 1777 Orbital Cellulitis 1777
OTHER MALIGNANCIES OF THE SKIN 1694 Kaposi’s Sarcoma 1694 Basal and Squamous Cell Carcinomas in the Immunocompromised Population
1747
1750
DIAGNOSTIC EVALUATION IMPAIRED VISION 1753
ULCERATIONS 1686 BENIGN TUMORS OF THE SKIN 1686 MALIGNANT TUMORS OF THE SKIN: SKIN CANCER 1687
1700
1706
Emergent/Resuscitative Phase of Burn Care 1710 Acute or Intermediate Phase of Burn Care 1718 Disorders of Wound Healing 1726 Rehabilitation Phase of Burn Care 1735
1670
Herpes Zoster 1670 Herpes Simplex 1671 Orolabial Herpes 1671 Genital Herpes 1671
Argon Laser
1705
MANAGEMENT OF THE PATIENT WITH A BURN INJURY 1710
1668
Impetigo 1668 Folliculitis, Furuncles, and Carbuncles 1669
DERMATOLOGIC AND PLASTIC RECONSTRUCTIVE SURGERY
1703
Classification of Burns 1705 Local and Systemic Responses to Burns
BACTERIAL INFECTIONS: PYODERMAS
BLISTERING DISEASES
57 Management of Patients With Burn Injury INCIDENCE OF BURN INJURY 1704 OUTLOOK FOR SURVIVAL AND RECOVERY PATHOPHYSIOLOGY OF BURNS 1705
Hydradenitis Suppurativa 1665 Seborrheic Dermatoses 1665 Acne Vulgaris 1666
VIRAL SKIN INFECTIONS
Carbon Dioxide Laser 1700 Pulse-Dye Laser 1701
SURGICAL PROCEDURES AND ENUCLEATION
1780
Orbital Surgeries 1780 Enucleation 1780
OCULAR CONSEQUENCES OF SYSTEMIC DISEASE 1700
Diabetic Retinopathy 1781 Cytomegalovirus Retinitis 1781 Hypertension-Related Eye Changes
1781
1782
CONCEPTS IN OCULAR MEDICATION ADMINISTRATION 1782
Contents Commonly Used Ocular Medications Nursing Management 1784
1783
ETHICAL ISSUES IN OPHTHALMOLOGY NURSING CONSIDERATIONS 1786
1785
59 Assessment and Management of Patients With Hearing and Balance Disorders
1789
ANATOMIC AND PHYSIOLOGIC OVERVIEW
1790
Anatomy of the External Ear 1790 Anatomy of the Middle Ear 1790 Anatomy of the Inner Ear 1792 Function of the Ears 1793
ASSESSMENT
ALTERED LEVEL OF CONSCIOUSNESS
DIAGNOSTIC EVALUATION 1795 HEARING LOSS 1797 CONDITIONS OF THE EXTERNAL EAR 1800
INCREASED INTRACRANIAL PRESSURE INTRACRANIAL SURGERY
SEIZURE DISORDERS
1866
1873
Seizures 1873 The Epilepsies 1874 Nursing Process: The Patient With Epilepsy Status Epilepticus 1880
1801
HEADACHE 1803
1806
1877
1881
62 Management of Patients With Cerebrovascular Disorders ISCHEMIC STROKE
1887
1880
Nursing Process: The Patient Recovering from an Ischemic Stroke 1895
HEMORRHAGIC STROKE
1808
1902
Nursing Process: The Patient With a Hemorrhagic Stroke 1905
AURAL REHABILITATION 1812
63 Management of Patients With Neurologic Trauma
Hearing Aids 1812 Implanted Hearing Devices 1814 Hearing Guide Dogs 1815
1910
HEAD INJURIES 1911 BRAIN INJURY 1913
14
Nursing Process: The Patient With a Brain Injury
SPINAL CORD INJURY
Neurologic Function
1818
60 Assessment of Neurologic Function ANATOMIC AND PHYSIOLOGIC OVERVIEW
1820
1821
1821
ASSESSMENT: THE NEUROLOGIC EXAMINATION Health History 1834 Clinical Manifestations 1834 Physical Examination 1835
1834
1917
1926
Nursing Process: The Patient With Acute Spinal Cord Injury 1931 Nursing Process: The Patient With Quadriplegia or Paraplegia 1935
64 Management of Patients With Neurologic Infections, Autoimmune Disorders, and Neuropathies INFECTIOUS NEUROLOGIC DISORDERS
DIAGNOSTIC EVALUATION 1842 Computed Tomography Scanning
1856
Nursing Process: The Patient Undergoing Intracranial Surgery 1868 Transsphenoidal Surgery 1873
Motion Sickness 1806 Ménière’s Disease 1807 Labyrinthitis 1808 Benign Paroxysmal Positional Vertigo Ototoxicity 1808 Acoustic Neuroma 1808
Anatomy of the Nervous System
1849 1850
Nursing Process: The Patient With Increased ICP 1860
Tympanic Membrane Perforation 1801 Acute Otitis Media 1801 Serous Otitis Media 1802 Chronic Otitis Media 1802 Nursing Process: The Patient Undergoing Mastoid Surgery Otosclerosis 1805 Middle Ear Masses 1805
Unit
1843
Nursing Process: The Patient With an Altered Level of Consciousness 1851
Cerumen Impaction 1800 Foreign Bodies 1800 External Otitis (Otitis Externa) 1800 Malignant External Otitis 1801 Masses of the External Ear 1801 Gapping Earring Puncture 1801
CONDITIONS OF THE INNER EAR
Positron Emission Tomography 1842 Single Photon Emission Computed Tomography Magnetic Resonance Imaging 1843 Cerebral Angiography 1844 Myelography 1844 Noninvasive Carotid Flow Studies 1844 Transcranial Doppler 1844 Electroencephalography 1845 Evoked Potential Studies 1845 Electromyography 1845 Nerve Conduction Studies 1846 Lumbar Puncture and Examination of Cerebrospinal Fluid 1846
61 Management of Patients With Neurologic Dysfunction
1793
Inspection of the External Ear 1793 Otoscopic Examination 1793 Evaluation of Gross Auditory Acuity 1795
CONDITIONS OF THE MIDDLE EAR
xxxi
1842
Meningitis 1943 Herpes Simplex Virus Encephalitis
1946
1942 1943
Contents
xxxii
Endoscopic Studies 2014 Other Studies 2015 Laboratory Studies 2015
Arthropod-Borne Virus Encephalitis 1947 Fungal Encephalitis 1947 Creutzfeldt-Jakob and New-Variant Creutzfeldt-Jakob Disease 1948
AUTOIMMUNE PROCESSES
NURSING IMPLICATIONS
Multiple Sclerosis 1949 Nursing Process: The Patient With Multiple Sclerosis 1952 Myasthenia Gravis 1956 Guillain-Barré Syndrome 1958 Nursing Process: The Patient With Guillain-Barré Syndrome 1959
CRANIAL NERVE DISORDERS
1962
Trigeminal Neuralgia (Tic Douloureux) Bell’s Palsy 1965
1962
Peripheral Neuropathies 1966 Mononeuropathy 1966
Neurologic Disorders
1969
ONCOLOGIC DISORDERS OF THE BRAIN AND SPINAL CORD 1970
1979
Parkinson’s Disease 1979 Nursing Process: The Patient With Parkinson’s Disease Huntington’s Disease 1986 Alzheimer’s Disease 1987 Amyotrophic Lateral Sclerosis 1988 Muscular Dystrophies 1989 Degenerative Disk Disease 1990 Herniation of a Cervical Intervertebral Disk 1992 Nursing Process: The Patient Undergoing a Cervical Discectomy 1993 Herniation of a Lumbar Disk 1994 Post-Polio Syndrome 1996
15
1983
2003
Structure and Function of the Skeletal System 2003 Structure and Function of the Articular System 2005 Structure and Function of the Skeletal Muscle System 2006
Imaging Procedures 2014 Nuclear Studies 2014
2014
2023
2024
Principles of Effective Traction 2026 Skin Traction 2026 Skeletal Traction 2028 Nursing Process: The Patient in Traction
2029
Joint Replacement 2031 Total Hip Replacement 2032 Total Knee Replacement 2035 Nursing Process: Preoperative Care of the Patient Undergoing Orthopedic Surgery 2039 Nursing Process: Postoperative Care of the Patient Undergoing Orthopedic Surgery 2041
2046 2047
COMMON PROBLEMS OF THE UPPER EXTREMITY
2002
DIAGNOSTIC EVALUATION
Arm Casts 2023 Leg Casts 2023 Body or Spica Casts
Acute Low Back Pain 2047 Nursing Process: The Patient With Acute Low Back Pain
66 Assessment of Musculoskeletal Function 2007
2018
2019
COMMON MUSCULOSKELETAL PROBLEMS
2000
Health History 2007 Physical Assessment 2010
Casting Materials 2018 Nursing Process: The Patient in a Cast
68 Management of Patients With Musculoskeletal Disorders
Musculoskeletal Function
ASSESSMENT
MANAGING CARE OF THE PATIENT IN A CAST
MANAGING THE PATIENT UNDERGOING ORTHOPEDIC SURGERY 2031
Primary Brain Tumors 1970 Cerebral Metastases 1975 Nursing Process: The Patient With Cerebral Metastases or Incurable Brain Tumor 1975 Spinal Cord Tumors 1977
ANATOMIC AND PHYSIOLOGIC OVERVIEW
2017
MANAGING THE PATIENT WITH SPLINTS AND BRACES 2024 MANAGING THE PATIENT WITH AN EXTERNAL FIXATOR 2025 MANAGING THE PATIENT IN TRACTION 2025
65 Management of Patients With Oncologic and Degenerative
Unit
67 Musculoskeletal Care Modalities
SPECIFIC CAST MANAGEMENT CONSIDERATIONS
DISORDERS OF THE PERIPHERAL NERVOUS SYSTEM 1966
DEGENERATIVE DISORDERS
2015
1949
2048
2052
Bursitis and Tendinitis 2052 Loose Bodies 2052 Impingement Syndrome 2052 Carpal Tunnel Syndrome 2052 Ganglion 2052 Dupuytren’s Contracture 2053 Nursing Process: The Patient Undergoing Surgery of the Hand or Wrist 2053
COMMON FOOT PROBLEMS
2054
Plantar Fasciitis 2055 Corn 2055 Callus 2055 Ingrown Toenail 2055 Hammer Toe 2055 Hallux Valgus 2055 Pes Cavus 2056 Morton’s Neuroma 2056 Flatfoot 2056 Nursing Process: The Patient Undergoing Foot Surgery
2056
Contents METABOLIC BONE DISORDERS
2057
Unit
Osteoporosis 2057 Nursing Process: The Patient With a Spontaneous Vertebral Fracture Related to Osteoporosis 2061 Osteomalacia 2063 Paget’s Disease 2063
MUSCULOSKELETAL INFECTIONS
THE INFECTIOUS PROCESS
2114
2115
Elements of Infection 2115 Colonization, Infection, and Disease Microbiology Report 2118
2068
2117
INFECTION CONTROL AND PREVENTION
2119
Organizations Involved in Infection Prevention 2119 Preventing Infection in the Community 2119 Preventing Infection in the Hospital 2122
EMERGING INFECTIOUS DISEASES
69 Management of Patients With Musculoskeletal Trauma CONTUSIONS, STRAINS, AND SPRAINS JOINT DISLOCATIONS 2076 SPORTS-RELATED INJURIES 2077
2075 2076
Rotator Cuff Tears 2078 Epicondylitis (Tennis Elbow) 2078 Lateral and Medial Collateral Ligament Injury 2078 Anterior and Posterior Cruciate Ligament Injury 2079 Meniscal Injuries 2079 Rupture of the Achilles Tendon 2079
FRACTURES 2079 FRACTURE HEALING AND COMPLICATIONS (EARLY AND DELAYED) 2083 Shock (Early) 2083 Fat Embolism Syndrome (Early) 2083 Compartment Syndrome (Early) 2084 Other Early Complications 2085 Delayed Union and Nonunion 2085 Avascular Necrosis of Bone (Delayed) 2086 Reaction to Internal Fixation Devices (Delayed) 2086 Complex Regional Pain Syndrome (Delayed) 2086 Heterotrophic Ossification (Delayed) 2086
FRACTURES OF SPECIFIC SITES
2086
Clavicle 2087 Humeral Neck 2087 Humeral Shaft 2087 Elbow 2089 Radial Head 2089 Radial and Ulnar Shafts 2089 Wrist 2090 Hand 2091 Pelvis 2091 Femur 2092 Femoral Shaft 2096 Tibia and Fibula 2102 Rib 2102 Thoracolumbar Spine 2102
2125
West Nile Virus 2126 Legionnaires’ Disease 2126 Lyme Disease 2127 Hantavirus Pulmonary Syndrome 2127 Ebola and Marburg Viruses 2128 Travel and Immigration 2128 Diarrheal Diseases 2129 Nursing Process: The Patient With Infectious Diarrhea 2130
SEXUALLY TRANSMITTED DISEASES
2132
Human Immunodeficiency Virus 2132 Syphilis 2133 Gonorrhea 2134 Chlamydia Trachomatis 2135 Nursing Process: The Patient With a Sexually Transmitted Disease 2135
HOME-BASED CARE OF THE PATIENT WITH AN INFECTIOUS DISEASE 2137 Reducing Risk 2137 Nursing Process: The Patient With an Infectious Disease 2138
71 Emergency Nursing
2147
SCOPE AND PRACTICE OF EMERGENCY NURSING Issues in Emergency Nursing Care 2148 Emergency Nursing and the Continuum of Care
PRINCIPLES OF EMERGENCY CARE Triage 2150 Assess and Intervene
2150
2151
AIRWAY OBSTRUCTION 2151 HEMORRHAGE 2152 HYPOVOLEMIC SHOCK 2156 WOUNDS 2156 TRAUMA 2157 Intra-abdominal Injuries 2158 Crush Injuries 2159 Multiple Injuries 2159 Fractures 2160
ENVIRONMENTAL EMERGENCIES
2103
Nursing Process: The Patient Undergoing an Amputation
2112
70 Management of Patients With Infectious Diseases
2064
Benign Bone Tumors 2068 Malignant Bone Tumors 2068 Metastatic Bone Disease 2068 Nursing Process: The Patient With a Bone Tumor 2069
AMPUTATION
16
Other Acute Problems
Osteomyelitis 2064 Nursing Process: The Patient With Osteomyelitis 2066 Septic (Infectious) Arthritis 2067
BONE TUMORS
xxxiii
2105
Heat Stroke 2161 Frostbite 2162 Hypothermia 2162
2161
2150
2148
Contents
xxxiv
Near-Drowning 2163 Decompression Sickness 2164 Anaphylactic Reaction 2164 Latex Allergy 2165 Injected Poisons: Stinging Insects Snake Bites 2166
POISONING
Violent Behavior 2178 Posttraumatic Stress Disorder 2179 Underactive or Depressed Patients 2179 Suicidal Patients 2179 2166
2167
Ingested (Swallowed) Poisons 2167 Inhaled Poisons: Carbon Monoxide Poisoning 2167 Skin Contamination Poisoning (Chemical Burns) 2169 Food Poisoning 2169
SUBSTANCE ABUSE 2170 Acute Alcohol Intoxication 2170 Alcohol Withdrawal Syndrome/Delirium Tremens
VIOLENCE, ABUSE, AND NEGLECT
2175
Family Violence, Abuse, and Neglect 2175 Sexual Assault 2176 Violence in the Emergency Department 2177
PSYCHIATRIC EMERGENCIES Overactive Patients
2178
2170
72 Terrorism, Mass Casualty, and Disaster Nursing Emergency Preparedness 2184 Initiating the Emergency Operations Plan Preparing for Terrorism 2188 Weapons of Terror 2189
2183 2186
Appendix A: Understanding Clinical Pathways 2199 Appendix B: Diagnostic Studies and Interpretation 2213
2178 Index I-1
●
Contributors
Sandra M. Annesi, RN, MSN Assistant Professor Nursing Program Daytona Beach Community College DeLand, Florida Chapter 25: Respiratory Care Modalities
Jill Cash, MSN, APRN, BC Family Nurse Practitioner Southern Illinois OB-GYN Associates, SC Carbondale, Illinois Chapter 59: Assessment and Management of Patients With Hearing and Balance Disorders
Judith C. Bautch, PhD, RN, CS Professor Department of Nursing Winona State University Winona, Minnesota Chapter 54: Assessment and Management of Patients With Rheumatic Disorders
Linda Carman Copel, PhD, RN, CS, CGP, DAPA Associate Professor Villanova University College of Nursing Villanova, Pennsylvania Chapter 4: Health Education and Health Promotion Chapter 6: Homeostasis, Stress, and Adaptation Chapter 7: Individual and Family Considerations Related to Illness
Jo Ann Brooks-Brunn, DNS, RN, FAAN, FCCP Assistant Professor Thoracic Surgery Pulmonary and Critical Care Medicine Indiana University School of Medicine Indianapolis, Indiana Chapter 23: Management of Patients With Chest and Lower Respiratory Tract Disorders Chapter 24: Management of Patients With Chronic Obstructive Pulmonary Disorders
Juliet Corbin, RNC, DNS, FNP Lecturer School of Nursing San Jose State University San Jose, California Chapter 10: Chronic Illness
Jacqueline Fowler Byers, PhD, RN, CNAA Associate Professor School of Nursing University of Central Florida Orlando, Florida Chapter 21: Assessment of Respiratory Function Kim Cantwell-Gab, BSN, RN, CVN, RVT, RDMS Vascular Surgery Nurse Specialist Department of Surgery, Division of Vascular Surgery University of Washington School of Medicine Seattle, Washington Chapter 31: Assessment and Management of Patients With Vascular Disorders and Problems of Peripheral Circulation Patricia E. Casey, RN, MSN Director, Regional Cardiovascular Program Kaiser Permanente Mid-Atlantic Region Rockville, Maryland Chapter 27: Management of Patients With Dysrhythmias and Conduction Problems Chapter 28: Management of Patients With Coronary Vascular Disorders Chapter 29: Management of Patients With Structural, Infectious, and Inflammatory Cardiac Disorders Chapter 30: Management of Patients With Complications From Heart Disease
Susanna G. Cunningham, RN, PhD, FAAN, FAHA Professor Department of Biobehavioral Nursing and Health Systems University of Washington School of Nursing Seattle, Washington Chapter 32: Assessment and Management of Patients With Hypertension Lana Currance, RN, BSN, CCRN Chief Nursing Officer National Medical Response System Colorado 2 DMAT/Central U.S. NMRT-Weapons of Mass Destruction Parker, Colorado Chapter 72: Terrorism, Mass Casualty, and Disaster Nursing Margaret A. Degler, RN, MSN, CRNP, CUNP Director, Continence Program West Office of the Center for Urologic Care of Berks County, P.C. West Reading, Pennsylvania Chapter 12: Health Care of the Older Adult Chapter 43: Assessment of Renal and Urinary Tract Function Chapter 44: Management of Patients With Upper or Lower Urinary Tract Dysfunction Chapter 45: Management of Patients With Urinary Disorders Nancy E. Donegan, RN, BS, MPH Director, Infection Control Washington Hospital Center Washington, D.C. Chapter 70: Management of Patients With Infectious Diseases v
vi
Contributors
Phyllis Dubendorf, RN, MSN, CS-ACNP Lecturer, Acute Care Nurse Practitioner Program School of Nursing University of Pennsylvania Philadelphia, Pennsylvania Chapter 61: Management of Patients With Neurologic Dysfunction Eleanor Fitzpatrick, RN, MSN, CRNP, CCRN Clinical Nurse Specialist Surgical ICU/Intermediate Surgical ICU Thomas Jefferson University Hospital Philadelphia, Pennsylvania Chapter 39: Assessment and Management of Patients With Hepatic Disorders Chapter 40: Assessment and Management of Patients With Biliary Disorders Mary Beth Flynn, RN, MS CNS/Clinical Educator University of Colorado Hospital Clinical Faculty University of Colorado Health Science Center Denver, Colorado Chapter 15: Shock and Multisystem Failure Kathleen K. Furniss, MSN, APN-C Nurse Practitioner, Women’s Health Women’s Health Initiative University of Medicine and Dentistry of New Jersey and Associates in Women’s Health Care Newark, New Jersey Chapter 46: Assessment and Management of Female Physiologic Processes Chapter 47: Management of Patients With Female Reproductive Disorders Paula Graling, RN, MSN, CNS Clinical Nurse Specialist Perioperative Services Inova Fairfax Hospital Falls Church, Virginia Chapter 18: Preoperative Nursing Management Chapter 19: Intraoperative Nursing Management Chapter 20: Postoperative Nursing Management Randolph E. Gross, RN, MS, CS, AOCN Clinical Nurse Specialist Evelyn H. Louder Breast Center Memorial Sloan-Kettering Cancer Center New York, New York Chapter 48: Assessment and Management of Patients With Breast Disorders Doreen Grzelak, RN, MSN, AOCN Operations Manager Medical Imaging Center Department of Radiology Reston Hospital Center Reston, Virginia Chapter 35: Management of Patients With Oral and Esophageal Disorders Chapter 37: Management of Patients With Gastric and Duodenal Disorders
Janice L. Hinkle, PhD, RN, CNRN Assistant Professor Villanova University College of Nursing Villanova, Pennsylvania Chapter 5: Health Assessment Chapter 62: Management of Patients With Cerebrovascular Disorders Chapter 65: Management of Patient With Oncologic and Degenerative Neurologic Disorders Ryan R. Iwamoto, ARNP, MN, AOCN Oncology Clinical Coordinator Genentech BioOncology, Inc. South San Francisco, California Nurse Practitioner Department of Radiation Oncology Virginia Mason Medical Center Clinical Instructor University of Washington and Seattle University Seattle, Washington Chapter 49: Assessment and Management of Problems Related to Male Reproductive Processes Joyce Young Johnson, RN, PhD, CCRN Assistant Chair Department of Nursing Georgia Perimeter College Clarkston, Georgia Chapter 1: Health Care Delivery and Nursing Practice Chapter 2: Community-Based Nursing Practice Chapter 3: Critical Thinking, Ethical Decision Making, and the Nursing Process Chapter 8: Perspectives in Transcultural Nursing Rhonda Kyanko, RN, MS Nursing Education Coordinator National Rehabilitation Hospital Washington, DC Chapter 11: Principles and Practices of Rehabilitation Pamela J. LaBorde, MSN, RN Clinical Nurse Specialist, Patient Care Services University of Arkansas Medical Sciences Center Little Rock, Arkansas Formerly, Clinical Nurse Specialist, Burn Unit Orlando Regional Medical Center Orlando, Florida Chapter 57: Management of Patients With Burn Injury Dale Halsey Lea, RN, MPH, CGC, APGN, FAAN Assistant Director Southern Maine Regional Genetics Services Foundations for Blood Research Scarborough, Maine Chapter 9: Genetics Perspectives in Nursing Practice Dorothy B. Liddel, RN, MSN, ONC Associate Professor (Retired) Department of Nursing Columbia Union College Tacoma Park, Maryland Chapter 66: Assessment of Musculoskeletal Function Chapter 67: Musculoskeletal Care Modalities Chapter 68: Management of Patients With Musculoskeletal Disorders Chapter 69: Management of Patients With Musculoskeletal Trauma
Contributors Martha V. Manning, RN, MSN Nurse Clinician Inova Emergency Care Center at Fairfax Fairfax, Virginia Chapter 34: Assessment of Digestive and Gastrointestinal Function Chapter 38: Management of Patients With Intestinal and Rectal Disorders Barbara J. Maschak-Carey, RN, MSN, CDE Clinical Nurse Specialist Department of Endocrinology, Diabetes and Metabolism University of Pennsylvania Health System Philadelphia, Pennsylvania Chapter 41: Assessment and Management of Patients With Diabetes Mellitus Agnes Masny, RN, MPH, MSN, CRNP Research Associate /Nurse Practitioner Population Science Division, Family Risk Assessment Program Fox Chase Cancer Center Philadelphia, Pennsylvania Chapter 9: Genetics Perspectives in Nursing Lou Ann McGinty, MSN, RN Nurse Science Clinical Specialist Capitol Health System Trenton, New Jersey Chapter 64: Management of Patients With Infectious, Inflammatory, and Autoimmune Neurologic Disorders Nancy A. Morrissey, RN,C, PhD Patient Care Director Mental Health and Behavioral Center Inova Alexandria Hospital Alexandria, Virginia Chapter 36: Gastrointestinal Intubation and Special Nutritional Modalities Martha A. Mulvey, RN, MS, CNS Advanced Practice Nurse Neurosciences University of Medicine and Dentistry of New Jersey, University Hospital Newark, New Jersey Chapter 14: Fluids and Electrolytes: Balance and Distribution Victoria Navarro, RN, MAS, MSN Director of Clinical Services Wilmer Eye Institute The Johns Hopkins Medical Institutions Baltimore, Maryland Chapter 58: Assessment and Management of Patients With Eye and Vision Disorders Donna Nayduch, RN-CS, MSN, CCRN Trauma Regional Director Banner Health Greeley, Colorado Chapter 71: Emergency Nursing Chapter 72: Terrorism, Mass Casualty, and Disaster Nursing
vii
Kathleen Nokes, PhD, RN, FAAN Professor Hunter-Bellevue School of Nursing New York, New York Chapter 52: Management of Patients With HIV Infection and AIDS Janet A. Parkosewich, RN, MSN, CCRN Cardiac Clinical Nurse Specialist Department of Patient Services Yale-New Haven Hospital New Haven, Connecticut Chapter 26: Assessment of Cardiovascular Function Anne Gallagher Peach, RN, MSN Chief Operating Officer M.D. Anderson Cancer Center Orlando Orlando, Florida Chapter 22: Management of Patients With Upper Respiratory Tract Disorders JoAnne Reifsnyder, PhD, RN, AOCN Postdoctoral fellow, Psychosocial Oncology School of Nursing University of Pennsylvania Philadelphia, Pennsylvania Chapter 17: End-of-Life Care Susan A. Rokita, RN, MS, CRNP Nurse Coordinator, Cancer Center Oncology Clinical Nurse Specialist Milton S. Hershey Medical Center of Pennsylvania State University Hershey, Pennsylvania Chapter 16: Oncology: Nursing Management in Cancer Care Al Rundio, PhD, RN, ANP Associate Professor Medical College of Pennsylvania/Hahnemann University College of Nursing and Health Professions Philadelphia, Pennsylvania Chapter 50: Assessment of Immune Function Chapter 51: Management of Patients With Immunodeficiency Chapter 53: Assessment and Management of Patients With Allergic Disorders Catherine Sackett, RN, BS, CANP Ophthalmic Research Nurse Practitioner Wilmer Eye Institute Retinal Vascular Center The Johns Hopkins Medical Institutions Baltimore, Maryland Chapter 58: Assessment and Management of Patients With Eye and Vision Disorders Linda Schakenbach, RN, CNS, MSN, CCRN, COCN, CWCN, CS Clinical Nurse Specialist, Critical Care Inova Alexandria Hospital Alexandria, Virginia Chapter 27: Management of Patients With Dysrhythmias and Conduction Problems Chapter 28: Management of Patients With Coronary Vascular Disorders Chapter 29: Management of Patients With Structural, Infectious, and Inflammatory Cardiac Disorders
viii
Contributors
Margaret A. Spera, NP, APRN Nurse Practitioner Family Medical Associates Ridgefield, Connecticut Assistant Clinical Professor Yale University School of Nursing New Haven, Connecticut Chapter 60: Assessment of Neurologic Function Cindy Stern, RN, MSN Cancer Network Coordinator University of Pennsylvania Cancer Center University of Pennsylvania Health System Philadelphia, Pennsylvania Chapter 16: Oncology: Nursing Management in Cancer Care Christine Tea, RN, MSN, CNA Patient Care Director Main OR Perioperative Services Inova Fairfax Hospital Falls Church, Virginia Chapter 18: Preoperative Nursing Management Chapter 19: Intraoperative Nursing Management Chapter 20: Postoperative Nursing Management Mary Laudon Thomas, RN, MS, AOCN Hematology Clinical Nurse Specialist Veterans’ Administration, Palo Alto Health Care System Palo Alto, California Chapter 33: Assessment and Management of Patients With Hematologic Disorders
Dorraine Day Watts, PhD, RN Interim Director of Research and Education Inova Health System Falls Church, Virginia Chapter 63: Management of Patients With Neurologic Trauma Joan Webb, RN, MSN Instructor College of Nursing Widener University Chester, Pennsylvania Chapter 40: Assessment and Management of Patients With Biliary Disorders Chapter 42: Assessment and Management of Patients With Endocrine Disorders Joyce S. Willens, RN, PhD Assistant Professor College of Nursing Villanova University Villanova, Pennsylvania Chapter 13: Pain Management Iris Woodard, RN-CS, BSN, ANP Nurse Practitioner Department of Dermatology Kaiser Permanente Springfield, Virginia Chapter 55: Assessment of Integumentary Function Chapter 56: Management of Patients With Dermatologic Problems
●
Contributorsand Reviewers Consultants
Debbie Amason, BSN, MS, RN Assistant Professor Floyd College Rome, Georgia William Ames, MSN, RN, FNP Associate Professor Elizabethtown Community College Elizabethtown, Kentucky Susan Arbogast, MS, RN Faculty Maricopa Community College District Nursing Program, Phoenix College Campus Phoenix, Arizona Gail Armstrong, ND, RN Assistant Professor University of Colorado School of Nursing Denver, Colorado Denise M. Ayers, MSN, RN Assistant Professor, Nursing Kent State University at Tuscarawas New Philadelphia, Ohio Valerie Benedix, BSN, RN Nursing Instructor Clovis Community College Clovis, New Mexico Ilene Borze, MS, CEN, RN Director, Nursing Continuing Education Faculty Gateway Community College Phoenix, Arizona Donna Bowren, RN, MSN, CNOR, CRNFA Interim Chairperson, Division of Nursing and Allied Health University of Arkansas Community College at Batesville Batesville, Arkansas Pat Bradley, RN, MEd MS Nursing Faculty Grossmont College El Cajon, California
Lynn Browning, RN, MSN BC Assistant Professor of Nursing Derry Patterson Wingo School of Nursing Charleston Southern University Charleston, South Carolina
Mary Elliot, BScN, MEd, RN Professor Humber College of Applied Arts & Technology Etobicoke, Ontario, Canada
Elizabeth Bruce, RN, MSN St. Clair Community College Chatham, Ontario
Cheryl Fenton, BHSc, RN Professor Mohawk College Burlington, Ontario, Canada
Shirley Cantrell, PhD, RN Associate Professor Piedmont College Demorest, Georgia
Kathie Folsom, RN, BSN, MS Department Chair Skagit Valley College Oak Harbor, Washington
Donna Cartwright, MS, APRN Dean, Professional and Applied Technology Education College of Eastern Utah Price, Utah
Donna Funk, MN/E ONC, RN Professor of Nursing Brigham Young University Rexburg, Idaho
Pattie Garrett Clark, MSN, RN Associate Professor of Nursing Abraham Baldwin College Tifton, Georgia Terry Cicero, MN, CCRN, RN Instructor, School of Nursing Seattle University Seattle, Washington Tracey D. Cooper, RN, MSN Director, Nursing Learning Resources Lab Instructor, South Plains College Levelland, Texas
Vicki Garlock, BSN, MSN, RN Professor, Nursing Department Pensacola Junior College Pensacola, Florida Mary Catherine Gebhart, MSN, CRRN, RN Instructor Georgia State University Atlanta, Georgia Donna Gullette, DNS, RN Associate Professor, Critical Care Chair Mississippi University for Women Columbus, Mississippi
Dolly I. Daniel, BSN, CDE, RNC Diabetes Nurse Specialist Inova Alexandria Hospital Alexandria, Virginia
Carol Heinrich, PhD, RN Associate Professor Department of Nursing East Stroudsburg University East Stroudsburg, Pennsylvania
Toni Doherty, MSN, RN Associate Professor Department Head, Nursing Dutchess Community College Poughkeepsie, New York
Sandra Hendelman, MS, RN Adjunct Professor of Nursing Palm Beach Community College Lake Worth, Florida South College
Sandra Edwards, BScN, RN Instructor Grant MacEwan College Edmonton, Alberta, Canada
Judith Ann Hughes, EdD, RN Associate Degree Nursing Coordinator Southwestern Community College Sylva, North Carolina
ix
x
Consultants and Reviewers
Sadie Pauline Hutson, MSN, RN, CRNP Cancer Research Training Award PreDoctoral Fellow National Cancer Institute, Clinical Genetics Branch Rockville, MD Jennifer Johnson. MSN, RN C Assistant Professor of Nursing Kent State University, Tuscarawas Campus New Philadelphia, Ohio Susan J. Lamanna, MA, MSN, RN ANP Associate Professor Onondaga Community College Syracuse, New York Joan Ann Leach, MS, ME, RNC Professor of Nursing Capital Community College Hartford, Connecticut Gayle Lee, PhD, RN, CCRN Faculty Brigham Young University Rexburg, Idaho Brenda Lohri-Posey, EdD, RN Assistant Dean of Learning, Nursing & Program Coordination Belmont Technical College St. Clairesville, Ohio Rhonda McLain, MN, RN Assistant Professor of Nursing Clayton College & State University Morrow, Georgia Pat Nashef, MHSc BA (CPMHN)c, RN Professional Practice Clinician, Mental Health Services
Halton Healthcare Services Oakville, Ontario Clinical Faculty McMaster University School of Nursing Hamilton, Ontario Lauren O’Hare, MSN, EdD, RN Assistant Professor of Nursing Wagner College Staten Island, New York Caroline Ostand, BC, MSN, RN Clinical Instructor University of Charleston Charleston, West Virginia Thena E. Parrott, PhD, RNCS Director, Associate Degree Nursing Program Blinn College Bryan, Texas Billie Phillips, PhD, RN, CDFS Assistant Professor Tennessee Wesleyan College Fort Sanders Nursing Department Athens, Tennessee Pam Primus, BSN, RN Nurse Educator Casper College Casper, Wyoming Betty E. Richards, RN, MSN Professor of Nursing Middle Georgia College Cochran, Georgia Patsy Ruppert Rider, MSN, CS, RN Clinical Instructor in Nursing University of Texas at Austin School of Nursing Austin, Texas
Kathleen L. Russ, MSN, RN Dean of Student Support/Health Careers Gateway Technical College Kenosha, Wisconsin Esther Salinas, MSN, MSEd, RN Associate Professor of Nursing Del Mar College Corpus Christi, Texas Marsha Sharp, MSN, RN Associate Professor Elizabethtown Community College Elizabethtown, Kentucky Kelli Simmons, MS, CS, M-SCNS, RN Cardiothoracic Clinical Nurse Specialist University of Missouri Hospitals and Clinics Columbia, Missouri Terri Small, MSN, RN C Assistant Professor of Nursing Waynesburg College Waynesburg, Pennsylvania Darla R. Ura, MA, ANP-CS, RN Clinical Associate Professor Emory University Atlanta, Georgia Weibin Yang, MD Assistant Professor of Physical Medicine and Rehabilitation Medicine (PM&R) University of Illinois Chicago, Illinois
How to use
Brunner & Suddarth’s Textbook of Medical-Surgical Nursing 10th edition
receives the nursing diagnoses Risk for Impaired Gas Exchange
requires
requires nursing interventions
outcomes should show improvement in Anxiety Control
Respiratory Monitoring
may be reduced by and
▲
The patient recovering from abdominal surgery with reluctance to move and a history of smoking
and
improves outcomes in
and
Cough Enhancement
improves outcomes in
Respiratory Status: Gas Exchange
Concept Maps—with NANDA, NIC, and NOC illustrate realitybased clinical scenarios for the visual learner.
requires Risk for Ineffective Airway Clearance
may be reduced by
and
and Risk for Thrombophlebitis
requires
secondary to
Embolus Precautions
and
limits
▼ Plans of Nursing Care— illustrate applications of the nursing process to diseases and disorders.
Pain Level reduces risk for and
and improves
Acute Pain
may be lessened by
Pain Management
and
may be lessened by
and
Impaired Physical Mobility
requires
helps to prevent
Plan Consequences: ofImmobility Nursing Care Care Physiologic of the Patient With COPD (Continued)
Nursing Interventions Rationale Expected Outcomes helps to and Nursing Diagnosis: Ineffective breathing pattern related to shortness of breath, mucus, bronchoconstriction, prevent and airway irritants Goal: Improvement in breathing pattern
Teaching: Prescribed Activity/Exercise
leads to Mobility Level 1. Teach patient diaphragmatic and pursedimproved lip breathing.
2. Encourage alternating activity with rest periods. Allow patient to make some decisions (bath, shaving) about care based on tolerance level. 3. Encourage use of an inspiratory muscle trainer if prescribed.
1. Helps patient prolong expiration time and decreases air trapping. With these techniques, patient will breathe more efficiently and effectively. 2. Pacing activities permits patient to perform activities without excessive distress.
• Practices pursed-lip and diaphragmatic breathing and uses them when short of breath and with activity
• Shows signs of decreased respiratory effort and paces activities
• Uses inspiratory muscle trainer as prescribed
3. Strengthens and conditions the respiratory muscles.
Nursing Diagnosis: Self-care deficits related to fatigue secondary to increased work of breathing and insufficient ventilation and oxygenation Goal: Independence in self-care activities 1. Teach patient to coordinate diaphragmatic breathing with activity (eg, walking, bending). 2. Encourage patient to begin to bathe self, dress self, walk, and drink fluids. Discuss energy conservation measures. 3. Teach postural drainage if appropriate.
1. This will allow the patient to be more active and to avoid excessive fatigue or dyspnea during activity. 2. As condition resolves, patient will be able to do more but needs to be encouraged to avoid increasing dependence. 3. Encourages patient to become involved in own care. Prepares patient to manage at home.
• Uses controlled breathing while bathing, bending, and walking
• Paces activities of daily living to alternate with rest periods to reduce fatigue and dyspnea
• Describes energy conservation strategies • Performs same self-care activities as before • Performs postural drainage correctly
Nursing Diagnosis: Activity intolerance due to fatigue, hypoxemia, and ineffective breathing patterns Goal: Improvement in activity tolerance
Chart 16-5 Home Care Checklist • Chemotherapy Administration
1. Muscles that are deconditioned consume 1. Support patient in establishing a regular more oxygen and place an additional burregimen of exercise using treadmill and den on the lungs. Through regular, graded exercycle, walking, or other appropriate exercise, these muscle groups become exercises, such as mall walking. more conditioned, and the patient can do a. Assess the patient’s current level of Patient moreCaregiver without getting as short of breath. functioning and develop exercise plan Graded exercise breaks the cycle of based on baseline functional status. ✓ debilitation. b. Suggest consultation with a physical ✓ therapist or pulmonary rehabilitation medications. ✓ ✓ program to determine an exercise pro✓ gram specific to the patient’s capability.✓ Have portable oxygen unit available if ✓ ✓ oxygen is prescribed for exercise.
• Performs activities with less shortness of breath
• Verbalizes need to exercise daily and
demonstrates an exercise plan to be carried out at home
At the completion of the home care instruction, the patient or caregiver will be able to: • Walks and gradually increases walking time and distance to improve physical • Demonstrate how to administer the chemotherapy agent in the home. condition • Exercises both upper and lower body • Demonstrate safe disposal of needles, syringes, IV supplies, or unused chemotherapy muscle groups • List possible side effects of chemotherapeutic agents. • List complications of medications necessitating a call to the nurse or physician. ✓ ✓ • List complications of medications necessitating a visit to the emergency department. Nursing Diagnosis: Ineffective coping related to reduced socialization, anxiety, depression, lower activity level, infusion • List names and telephone numbers of resource personnel involved in care (ie, home care nurse, and the inability to work services, IV vendor, equipment company). ✓ ✓ Goal: Attainment of an optimal level of coping ✓ ✓ • Explain treatment plan (protocol) and importance of upcoming visits to physician. 1. Help the patient develop realistic goals.
▲ Home Care Checklists—include guidelines on goals and management of home-based patients.
2. Encourage activity to level of symptom tolerance.
1. Developing realistic goals will promote a sense of hope and accomplishment rather than defeat and hopelessness. 2. Activity reduces tension and decreases degree of dyspnea as patient becomes conditioned.
• Expresses interest in the future • Participates in the discharge plan • Discusses activities or methods that can be performed to ease shortness of breath
• Uses relaxation techniques appropriately • Expresses interest in a pulmonary rehabilitation program
(continued)
Physiology/Pathophysiology
Chart 17-6
• ASSESSMENT
Nursing Assessment of Symptoms Associated With Terminal Illness
A. Rhinitis
Edematous conchae; polyps may develop
• How is this symptom affecting the patient’s life? • What is the meaning of the symptom to the patient? To the family?
• How does the symptom affect physical functioning, mobility, • • • •
Occluded sinus openings Enlarged nasal mucosa
• •
Discharging mucus
comfort, sleep, nutritional status, elimination, activity level, and relationships with others? What makes the symptom better? What makes it worse? Is it worse at any particular time of the day? What are the patient’s expectations and goals for managing the symptom? The family’s? Chart 16-4 • PHARMACOLOGY How is the patient coping with the symptom? Investigational Antineoplastic Therapies What is the economic effect of the symptom and its and Clinical Trials management?
Evaluation of the effectiveness and toxic potential of promising new modalities for preventing, diagnosing, and treating cancer is accom-
B. Sinusitis
Adapted from Jacox, A., Carr, D. B., & Payne, R. (1994). Management of plished through clinical trials. Before new chemotherapy agents are cancer pain. Rockville, MD: AHCPR. approved for clinical use, they are subjected to rigorous and lengthy
Thick mucus occludes sinus cavity and prevents drainage
▲ Assessment Displays— provide clinical features of diseases and disorders and include guidelines for assessing health history and exam findings.
FIGURE 22-1 Pathophysiologic processes in rhinitis and sinusitis. Although pathophysiologic processes are similar in rhinitis and sinusitis, they affect different structures. In rhinitis (A), the mucous membranes lining the nasal passages become inflamed, congested, and edematous. The swollen nasal conchae block the sinus openings, and mucus is discharged from the nostrils. Sinusitis (B) is also marked by inflammation and congestion, with thickened mucous secretions filling the sinus cavities and occluding the openings.
▲
Pharmacology Charts—review ▲ Pathophysiology Displays—
recent or common drug therapies with discussion of clinical trials where appropriate.
▲
utilize illustrations and algorithms to demonstrate processes.
evaluations to identify beneficial effects, adverse effects, and safety. • Phase I clinical trials determine optimal dosing, scheduling, and toxicity. • Phase II trials determine effectiveness with specific tumor types and further define toxicities. Participants in these early trials are most often those who have not responded to standard forms of treatment. Because phase I and II trials may be viewed as last-chance efforts, patients and families are fully informed about the experimental nature of the trial therapies. Although it is hoped that investigational therapy will effectively treat the disease, the purpose of early phase trials is to gather information concerning maximal tolerated doses, adverse effects, and effects of the antineoplastic agents on tumor growth. • Phase III clinical trials establish the effectiveness of new medications or procedures as compared with conventional approaches. Nurses may assist in the recruitment, consent, and education processes for patients who participate. In many cases, nurses are instrumental in monitoring adherence, assisting patients to adhere to the parameters of the trial, and documenting data describing patients’ responses. The physical and emotional needs of patients in clinical trials are addressed in much the same way as those of patients who receive standard forms of cancer treatment. • Phase IV testing further investigates medications in terms of new uses, dosing schedule, and toxicities.
Chart 25-3
Breathing Exercises
Risk Factors for Hypoventilation
General Instructions • Breathe slowly and rhythmically to exhale completely and empty the lungs completely. • Inhale through the nose to filter, humidify, and warm the air before it enters the lungs. • If you feel out of breath, breathe more slowly by prolonging the exhalation time. • Keep the air moist with a humidifier.
• Limited neurologic impulses transmitted from the brain to the respiratory muscles, as in spinal cord trauma, cerebrovascular accidents, tumors, myasthenia gravis, Guillain-Barré syndrome, polio, and drug overdose • Depressed respiratory centers in the medulla, as with anesthesia and drug overdose • Limited thoracic movement (kyphoscoliosis), limited lung movement (pleural effusion, pneumothorax), or reduced functional lung tissue (chronic pulmonary diseases, severe pulmonary edema)
Diaphragmatic Breathing Goal: To use and strengthen the diaphragm during breathing • Place one hand on the abdomen (just below the ribs) and the other hand on the middle of the chest to increase the awareness of the position of the diaphragm and its function in breathing. • Breathe in slowly and deeply through the nose, letting the abdomen protrude as far as possible. • Breathe out through pursed lips while tightening (contracting) the abdominal muscles. • Press firmly inward and upward on the abdomen while breathing out. • Repeat for 1 minute; follow with a rest period of 2 minutes. • Gradually increase duration up to 5 minutes, several times a day (before meals and at bedtime).
factors that may impair health (eg, carcinogens, environmental factors), and offer preventive measures to sidestep them.
Gerontologic Considerations Factors Contributing to Urinary Tract Infection in Older Adults
▲
Gerontologic Considerations—
provide specific information relevant to the older population.
▲
Pursed-Lip Breathing Goal: To prolong exhalation and increase airway pressure during expiration, thus reducing the amount of trapped air and the amount of airway resistance. • Inhale through the nose while counting to 3—the amount of time needed to say “Smell a rose.” • Exhale slowly and evenly against pursed lips while tightening the abdominal muscles. (Pursing the lips increases intratracheal pressure; exhaling through the mouth offers less resistance to expired air.) • Count to 7 while prolonging expiration through pursed lips—the length of time to say “Blow out the candle.” • While sitting in a chair: Fold arms over the abdomen. Inhale through the nose while counting to 3. Bend forward and exhale slowly through pursed lips while counting to 7. • While walking: Inhale while walking two steps. Exhale through pursed lips while walking four or five steps.
Risk Factor Charts—outline
Chart 21-8
• P A T I E N T E D U C A T I ON
• • • • •
High incidence of chronic illness Frequent use of antimicrobial agents Presence of infected pressure ulcers Immobility and incomplete emptying of bladder Use of a bedpan rather than a commode or toilet
Patient Education Boxes—provide suggestions on such topics as self-care, or how to cope with health challenges.
5 GAS EXCHANGE AND RESPIRATORY FUNCTION How toUnituse continued
xvi
!
NURSING ALERT It is the responsibility of all nurses, and particularly perianesthesia and perioperative nurses, to be aware of latex allergies, necessary precautions, and products that are latex-free (Meeker & Rothrock, 1999). Hospital staff are also at risk for developing a latex allergy secondary to repeated exposure to latex products.
▲ Nursing Alerts—offer brief tips for clinical practice and red-flag warnings to help students avoid common mistakes.
NURSING RESEARCH PROFILE 12-2
Identification of Agitation in Patients with Alzheimer’s Disease
Glossary by the adrenal cortex; they are involved in carbohydrate, protein, and fat metabolism and have anti-inflammatory properties gluconeogenesis: the formation of glucose, especially by the liver from noncarbohydrate sources such as amino acids and the glycerol portion of fats guided imagery: use of the imagination to achieve relaxation or direct attention away from uncomfortable sensations or situations homeostasis: a steady state within the body; the stability of the internal environment hyperplasia: an increase in the number of new cells hypoxia: inadequate supply of oxygen to the cell infectious agents: biologic agents, such as viruses, bacteria, rickettsiae, mycoplasmas, fungi, protozoa, and nematodes, that cause disease in people inflammation: a localized, protective reaction of tissue to injury, irritation, or infec-
adaptation: a change or alteration designed to assist in adapting to a new situation or environment adrenocorticotropic hormone (ACTH): a hormone produced by the anterior lobe of the pituitary gland that stimulates the secretion of cortisone and other hormones by the adrenal cortex antidiuretic hormone (ADH): a hormone secreted by the posterior lobe of the pituitary gland that constricts blood vessels, elevates blood pressure, and reduces the excretion of urine catecholamines: any of the group of amines (such as epinephrine, norepinephrine, or dopamine) that serve as neurotransmitters coping: the cognitive and behavioral strategies used to manage the stressors that tax a person’s resources dysplasia: a change in the appearance of a cell after exposure to chronic irritation glucocorticoids: the group of steroid hormones, such as cortisol, that are produced
Whall, A. L., Black, M. E. A., Yankou, D. J., et al. (1999). Nurse aides’ identification of onset and level of agitation in late stage dementia patients. American Journal of Alzheimer’s Disease, 14, 202–206.
tion, manifested by pain, redness, heat, swelling, and sometimes loss of function metabolic rate: the speed at which some substances are broken down to yield energy for bodily processes and other substances are synthesized metaplasia: a cell transformation in which a highly specialized cell changes to a less specialized cell negative feedback: feedback that decreases the output of a system positive feedback: feedback that increases the output of a system steady state: a stable condition that does not change over time, or when change in one direction is balanced by change in an opposite direction stress: a disruptive condition that occurs in response to adverse influences from the internal or external environments vasoconstriction: the narrowing of a blood vessel
▲ Glossary—at the beginning of every chapter, helps students learn vocabulary. ▲
Purpose Nursing assistants provide the majority of care to patients in nursing homes. They are vital links in the early identification, and therefore in the treatment, of agitation in patients with Alzheimer’s disease. Nurses’ aides (NAs) are sometimes characterized as unwilling or unable to manage patients’ agitation. This study examines the process by which nurses’ aides can successfully identify this agitation.
Nursing Research Profiles—contain research samples with purpose of research, study sample, and design and findings, and implications for use in evidence-based nursing.
Design NAs from five different nursing homes owned by the same corporate entity were asked to participate in the study. Criteria to participate included being employed for at least 1 year. (Research demonstrates that NAs who remain at a facility longer than 1 year Chart 25-15 usually have a commitment to those they serve.) The NAs did not GUIDELINES FOR Care of the Patient Being Weaned From Mechanical Ventilation receive any additional wages and were only promised a letter to inRATIONALE dicate that they had participated in the study. Each NA received ap-NURSING INTERVENTIONS 1. Careful assessment of multiple weaning indices helps to deterAssess patient for weaning criteria: Vital capacity—10 to 15 mL/kg proximately 1 hour of training via audio tapes and conversation with1. Maximum mine readiness for weaning. When the criteria have been met, inspiratory pressure (MIP) at least –20 cm H O nurse experts. Each NA was then paired with a nurse expert to as- Tidal volume—7 to 9 mL/kg the patient’s likelihood of successful weaning increases. Minute ventilation—6 L/min sess his or her skill at appropriately identifying levels of agitation in Rapid/shallow breathing index—below 100 breaths/minute/L patients with late-stage Alzheimer’s disease. PaO greater than 60 mm Hg with FiO less than 40% 2
2
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2. Monitor activity level, assess dietary intake, and monitor results of laboratory tests of nutritional status.
Conclusions This study demonstrated that NAs with a minimum of 1 year of3. Assess the patient’s and family’s understanding of the weaning employment did an excellent job in acquiring new observation process and address any concerns about the process. Explain that patient may feel short of breath initially and provide encourskills with only 1 hour of training and positive reinforcement via a the agement as needed. Reassure the patient that he or she will be atletter noting their participation in this study. The NAs’ assessment tended closely and that if the weaning attempt is not successful, it can be tried again later. of signs of agitation agreed with that of the nurse expert more than4. Implement the weaning method prescribed: A/C, IMV, SIMV, 90% of the time. All the NAs involved reported gaining helpful in- PSV, PAV, CPAP, or T-piece. sights in managing agitated behavior as a result of participation in 5. Monitor vital signs, pulse oximetry, ECG, and respiratory pattern the study.
constantly for the first 20 to 30 minutes and every 5 minutes after that until weaning is complete.
Implications for PracticeChart 22-7 • Ethics and Related Issues 6. Maintain a patent airway; monitor arterial blood gas levels and The results of this study support the ability of NAs to accurately pulmonary function tests. Suction the airway as needed. observe and report agitated 7. In collaboration with the physician, terminate the weaning process Situationbehavior as a result of a brief training if adverse reactions occur. These include a heart rate increase of A 68-year-old attorney that was diagnosed cancer of the larynx session using adult learning principles stressed with the importance 20 beats/min, systolic blood pressure increase of 20 mm Hg, a 8 years ago. He was treated successfully with radiation therapy, redecrease in oxygen saturation to less than 90%, respiratory rate of their input into the training and learning objectives. Early obsulting in an altered voice quality. Recently, he has complained less of than 8 or greater than 20 breaths/minute, ventricular dysservation and reporting of agitated behavior is important shortness of breath and difficulty swallowing.toInprevent the pastrhythmias, few fatigue, panic, cyanosis, erratic or labored breathing, paradoxical chest movement. months,tohethe also level has noticed a marked change in his voice and physagitation from increasing of physical aggression.
8. If the weaning process continues, measure tidal volume and minute ical condition, which he attributed to “winter colds.” ventilation every 20 to 30 minutes; compare with the patient’s After a complete physical exam and an extensive diagnostic desired values, which have been determined in collaboration workup and biopsy, it is determined that the cancer has recurred withatthe physician. a new primary site. His health care provider recommends surgery 9. Assess for psychological dependence if the physiologic parameters (a total laryngectomy) and chemotherapy as the best options.indicate The weaning is feasible and the patient still resists. patient states that he is not willing to “lose my voice and my livelihood” but instead will “take my chances.” He has also expressed concern about his quality of life after surgery. His family has approached you about trying to convince him to have surgery.
4. The prescribed weaning method should reflect the patient’s individualized criteria for weaning and weaning history. By having different methods to choose from, the physician can select the one that best fits the patient. 5. Monitoring the patient closely provides ongoing indications of success or failure. 6. These values can be compared to baseline measurements to evaluate weaning. Suctioning helps to reduce the risk of aspiration and maintain the airway. 7. These signs and symptoms indicate an unstable patient at risk for hypoxia and ventricular dysrhythmias. Continuing the weaning process can lead to cardiopulmonary arrest.
8. These values help to determine if weaning is successful and should be continued. 9. Psychological dependence is a common problem after mechanical ventilation. Possible causes include fear of dying and depression from chronic illness. It is important to address this issue before the next weaning attempt.
▲ Procedure Guidelines Charts—offer nursing
Dilemma The patient’s right to refuse treatment conflicts with the family’s wishes and recommendation from his health care provider.
activities and rationales for important skills.
Ethics and Related Issues—showcase brief scenarios and present possible ethical dilemmas for discussion.
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Discussion 1. Is the patient making a decision based upon all pertinent information concerning his health status, treatment, options, risk/benefits, and long-term prognosis? 2. What arguments can be made to support the patient’s decision to forego treatment? 3. What arguments can be made to question the patient’s decision to forego treatment?
2. Reestablishing independent spontaneous ventilation can be physically exhausting. It is crucial that the patient have enough energy reserves to succeed. Providing periods of rest and recommended nutritional intake can increase the likelihood of successful weaning. 3. The weaning process can be psychologically tiring; emotional support can help promote a sense of security. Explaining that weaning will be attempted again later helps reduce the sense of failure if the first attempts are unsuccessful.
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Preface
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s the 21st century begins, nurses face a future characterized by changes comparable to those of no preceding century:
• Science and technology have made the world smaller by • • •
making it more accessible. Mass communication is more widespread, and information is now just an instant away and very easy to obtain. Economies are more global than regional. Industrial and social changes have made world travel and cultural exchange common.
Today’s nurses enter a realm of opportunities and challenges for providing high-quality, evidence-based care in traditional as well as new and innovative health care settings. The rapid changes in health care mandate that nurses be prepared to provide or plan care across the continuum of settings—from hospital or clinic, to home, to community agencies or hospice settings—and during all phases of illness. Recent research has indicated that nurses make significant contributions to the health care outcomes of patients who are hospitalized. Therefore, today’s nurses must be prepared to identify patients’ short- and long-term needs quickly and to collaborate effectively with patients and families, other members of the health care team, and community agencies to create a seamless system of care. The continued emphasis on health promotion efforts to keep well people healthy and to promote a higher level of well-being among those with acute and chronic illnesses requires today’s nurses to assist patients in adopting healthy lifestyles and strategies. Mapping of the human genome and other advances in genetics have moved the issue of genetics to the bedside and increased the need for nurses to become knowledgeable about genetics-related issues. In preparing for these vast opportunities and responsibilities, today’s nurses must be well informed and up-to-date, not only in nursing knowledge and skills but also in research findings, scientific advances, and the ethical dilemmas inherent in many areas of clinical practice. More than ever, today’s nurses need to think critically, creatively, and compassionately. This tenth edition of Brunner & Suddarth’s Textbook of MedicalSurgical Nursing is designed for the 21st century and nurses’ need to be knowledgeable, highly skilled, perceptive, caring, and compassionate. A goal of the textbook is to provide balanced attention to the art and science of adult medical-surgical nursing. It addresses nursing care issues from a physiological, pathophysiological, and psychosocial context and assists the reader to identify priorities of care from that context.
ABOUT THE TENTH EDITION The tenth edition of Brunner and Suddarth’s Textbook of Medical Surgical Nursing was constructed to provide today’s nursing students with an understanding of the nurse’s role in health and illness within evolving practice environments and across the spectrum of health and illness. The textbook’s content has been revised and updated by experts in the field to reflect current practice and advances in health care and technology.
NEW CHAPTERS: GENETICS, END-OF-LIFE CARE, AND BIOTERRORISM Nursing knowledge is constantly expanding. Chapter 9, Genetics Perspectives in Nursing Practice, was written in response to genetics information identified during the last few years. Every nurse needs to be aware of the influence of genetics on health and illness, and every nurse needs to have the knowledge and skill to answer patients’ questions concerning their heredity and health. In addition to Chapter 9, genetics content has been incorporated into each clinical unit of the textbook. Chapter 17, End-of-Life Care, also new to the tenth edition, addresses some of the questions posed by technologies that can prolong life, often in the face of insurmountable obstacles. The chapter discusses the nurse’s role as it pertains to quality of life, prolongation of dying, pain relief, allocation of resources, ethical issues, communication, healing, spirituality, and patient and family care. It emphasizes the pivotal role of the nurse in providing end-of-life care. A third new chapter—Chapter 72, Terrorism, Mass Casualty, and Disaster Nursing—completes the text by reviewing the nurse’s role in relation to patients affected by terrorism and other disasters. Among the issues addressed are emergency preparedness and planning, triage in cases of mass casualty, radiation, chemical and biologic weapons, ethical conflict, stress management, and survival.
NANDA, NIC, NOC: LINKS, LANGUAGES, AND CONCEPT MAPS Although Brunner & Suddarth’s Textbook of Medical-Surgical Nursing has long used nursing diagnoses developed by the North American Nursing Diagnosis Association (NANDA), this edition presents the links between the NANDA diagnoses and the Nursing Interventions Classification (NIC) and Nursing-sensitive Outcomes Classification (NOC). The opening page of each unit presents a concept map illustrating these three classification systems and their relationships. Each unit’s concept map is accompanied by a case study and a chart presenting examples of actual NANDA, NIC, and NOC terminologies related to the case study. This material is included to introduce the reader to the NIC and NOC language and classifications and bring them to life in the clinical realm. Faculty and students alike may use some of the issues presented in the case studies as a springboard for developing their own concept maps.
RECENT NURSING RESEARCH AND OTHER FEATURES As before, Nursing Research Profiles included in the chapters identify the implications and applications of recent nursing research findings for nursing practice. The chapters also include charts and text detailing special considerations in caring for the elderly patient and for those with disabilities. xi
Preface
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TEACHING TOOLBOX
• CD-ROM to help students test their knowledge and enhance
Each chapter opens with Learning Objectives and a Glossary. Throughout the text the reader will find Nursing Alerts as well as specialized charts focusing on
• • • • • • • • • • • •
Physiology/Pathophysiology Risk Factors Assessment Plans of Nursing Care Pharmacology Home Care Patient Education Health Promotion Ethics and Related Issues Guidelines Gerontological Considerations Genetics in Nursing Practice
Illustrations, photographs, charts, and tables supplement the text and round out the applied-learning experience. Each chapter concludes with Critical Thinking Exercises, References and Selected Readings, and a list of specialized Resources and Websites.
MANY MORE OF THE LATEST RESOURCES Additional learning tools accompany the tenth edition and offer visual, tactile, and auditory reinforcement of the text. These resources include:
• • • •
their understanding of medical-surgical nursing. This CD includes 500 self-study questions organized by unit; 3000 bonus NCLEX-style cross-disciplinary questions; 3-D animated illustrations that explain common disease processes; and interactive clinical simulations. Student Study Guide to further enhance the learning experience (available at student bookstores) Instructor’s Resource CD-ROM to help facilitate classroom preparation, with an instructor’s manual, test generator, and searchable image collection, among other features Supplemental cartridges for Blackboard and WebCT Connection Website—Get connected at connection.LWW. com/go/smeltzer.
The tenth edition of Brunner and Suddarth’s Textbook of Medical-Surgical Nursing continues the tradition of presenting up-to-date content that addresses the art and science of nursing practice. The updating of the material and use of a variety of teaching methods to convey that content are intended to provide the nursing student and other users of the textbook with information needed to provide quality care to patients and families across health care settings and in the home. Suzanne C. O’Connell Smeltzer, RN, EDD, FAAN Brenda G. Bare, RN, MSN
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Health Care Delivery and Nursing Practice
LEARNING OBJECTIVES
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On completion of the chapter, the learner will be able to: 1. Define health and wellness. 2. Describe factors causing significant changes in the health care 3. 4. 5.
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delivery system and their impact on the health care field and the nursing profession. Describe the practitioner, leadership, and research roles of the nurse. Describe nursing care delivery models. Discuss expanded nursing roles.
Chapter 1
T
he health care industry, like other industries in U.S. society, has experienced profound changes during the past several decades. Nursing, as a health care profession and a major component of the health care delivery system, is significantly affected by shifts in the health care industry. In addition, nursing has been and will continue to be an important force in shaping the future of the health care system.
The Health Care Industry and the Nursing Profession Although the delivery of nursing care has been affected by changes occurring in the health care system, the definition of nursing has continued to distinguish nursing care and identify the major aspects of nursing care.
NURSING DEFINED Since the time of Florence Nightingale, who wrote in 1858 that the goal of nursing was “to put the patient in the best condition for nature to act upon him,” nursing leaders have described nursing as both an art and a science. However, the definition of nursing has evolved over time. The American Nurses Association (ANA), in its Social Policy Statement (ANA, 1995), defined nursing as “the diagnosis and treatment of human responses to health and illness” and provided the following illustrative list of phenomena that are the focus for nursing care and research:
• Self-care processes • Physiologic and pathophysiologic processes in areas such as • • • • • • • •
rest, sleep, respiration, circulation, reproduction, activity, nutrition, elimination, skin, sexuality, and communication Comfort, pain, and discomfort Emotions related to experiences of health and illness Meanings ascribed to health and illnesses Decision making and ability to make choices Perceptual orientations such as self-image and control over one’s body and environments Transitions across the life span, such as birth, growth, development, and death Affiliative relationships, including freedom from oppression and abuse Environmental systems
Health Care Delivery and Nursing Practice
word is one of dependence. For this reason, many nurses prefer to use the term client, which is derived from a Latin verb meaning “to lean,” connoting alliance and interdependence. For the purposes of this book, the term patient will be used throughout, but with the understanding that either term is acceptable. The patient who seeks care for a health problem or problems (increasing numbers of people have multiple health problems) is also an individual, a member of a family, and a citizen of the community. Patients’ needs vary depending on their problem, associated circumstances, and past experiences. One of the nurse’s important functions in health care delivery is to identify the patient’s immediate needs and take measures to address them.
The Patient’s Basic Needs Certain needs are basic to all people and require satisfaction accordingly. Such needs are addressed on the basis of priority, meaning that some needs are more pressing than others. Once an essential need is met, the person experiences a need on a higher level. Approaching needs according to priority reflects Maslow’s hierarchy of needs (Fig. 1-1).
Maslow’s Hierarchy Maslow ranked human needs as follows: physiologic needs; safety and security; belongingness and affection; esteem and self-respect; and self-actualization, which includes self-fulfillment, desire to know and understand, and aesthetic needs. Lower-level needs always remain, but a person’s ability to pursue higher-level needs indicates that he or she is moving toward psychological health and well-being. Such a hierarchy of needs is a useful organizational framework that can be applied to the various nursing models for assessment of a patient’s strengths, limitations, and need for nursing interventions.
Selfactualization
Nurses have a responsibility to carry out their role as defined in the Social Policy Statement, to comply with the nurse practice act of the state where they practice, and to comply with the code for nurses as spelled out by the International Council of Nurses and the ANA. Understanding the needs of health care consumers and the health care delivery system, including the forces that affect nursing and health care delivery, will provide a foundation for examining the delivery of nursing care.
Esteem and self-respect Belongingness and affection
Safety and security
THE PATIENT/CLIENT: CONSUMER OF NURSING AND HEALTH CARE The central figure in health care services is, of course, the patient. The term patient, which is derived from a Latin verb meaning “to suffer,” has traditionally been used to describe those who are recipients of care. The connotation commonly attached to the
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Physiologic needs
FIGURE 1-1
This scheme of Maslow’s hierarchy of human needs shows how a person moves from fulfillment of basic needs to higher levels of needs, with the ultimate goal being integrated human functioning and health.
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Unit 1
BASIC CONCEPTS IN NURSING PRACTICE
HEALTH CARE IN TRANSITION Changes occurring in health care delivery and nursing are the result of societal, economic, technological, scientific, and political forces that have evolved throughout the 20th and into the 21st century. Among the most significant changes are shifts in population demographics, particularly the increase in the aging population and the cultural diversity of the population; changing patterns of diseases; increased technology; increased consumer expectations; the high costs of health care and changes in health care financing; and other health care reform efforts. These changes have led to institutional restructuring, staff downsizing, increased outpatient care services, decreased lengths of hospital stay, and more care being provided in the community and in the home. Such changes are having a dramatic influence on where nurses practice, with an increasing trend for nurses to provide health care in community and home settings. Indeed, these changes have a dynamic influence on our view of health and illness and therefore affect the focus of nursing and health care. As an increasing proportion of the population reaches age 65 years and older, and with the shift in disease patterns from acute illnesses to chronic illnesses, the traditional disease management and care focus of the health care professions has expanded. There is growing concern about emerging infectious diseases, trauma, and bioterrorism. The health care focus must center more on prevention, health promotion, and management of chronic conditions than in previous times. This shift in focus coincides with a nationwide emphasis on cost control and resource management directed toward providing cost-efficient and cost-effective health care services to the population as a whole.
Health,Wellness, and Health Promotion The health care system of the United States, which traditionally has been disease oriented, is currently placing greater emphasis on health and its promotion. Similarly, a significant portion of nursing’s workforce formerly was focused on the care of patients with acute conditions, but now a growing portion is directing its efforts toward health promotion and disease prevention.
HEALTH How health is perceived depends on how health is defined. In the preamble to its constitution, the World Health Organization (WHO) defines health as a “state of complete physical, mental, and social well-being and not merely the absence of disease and infirmity” (Hood & Leddy, 2002). Such a definition of health does not allow for any variation in degrees of wellness or illness. On the other hand, the concept of a health–illness continuum allows for a greater range in describing a person’s health status. By viewing health and illness on a continuum, it is possible to consider a person as having neither complete health nor complete illness. Instead, a person’s state of health is ever-changing and has the potential to range from high-level wellness to extremely poor health and imminent death. The model of the health–illness continuum makes it possible to view a person as simultaneously possessing degrees of both health and illness. The limitations of the WHO definition of health are clear in relation to chronic illness and disability. A chronically ill person cannot meet the standards of health as established by the WHO definition. However, when viewed from the perspective of the health–illness continuum, people with chronic illness or disabil-
ity can be understood as having the potential to attain a high level of wellness, if they are successful in meeting their health potential within the limits of their chronic illness or disability.
WELLNESS Wellness has been defined as being equivalent to health. Cookfair (1996) indicated that wellness “includes a conscious and deliberate approach to an advanced state of physical, psychological, and spiritual health and is a dynamic, fluctuating state of being” (p. 149). Leddy and Pepper (1998) contended that wellness is indicated by the capacity of the person to perform to the best of his or her ability, the ability to adjust and adapt to varying situations, a reported feeling of well-being, and a feeling that “everything is together” and harmonious. With this in mind, it becomes evident that the goal of health care providers is to promote positive changes that are directed toward health and well-being. The fact that the sense of wellness has a subjective aspect emphasizes the importance of recognizing and responding to patient individuality and diversity in health care and nursing.
HEALTH PROMOTION Today, increasing emphasis is placed on health, health promotion, wellness, and self-care. Health is seen as resulting from a lifestyle that is oriented toward wellness. The result has been the evolution of a wide range of health promotion strategies, including multiphasic screening, genetic testing, lifetime health monitoring programs, environmental and mental health programs, risk reduction, and nutrition and health education. A growing interest in self-care skills is evidenced by the large number of healthrelated publications, conferences, and workshops designed for the lay public. Individuals are increasingly knowledgeable about their health and are encouraged to take more interest in and responsibility for their health and well-being. Organized self-care education programs emphasize health promotion, disease prevention, management of illness, self-medication, and judicious use of the professional health care system. In addition, well over 500,000 self-help groups and numerous web sites and chat groups exist for the purpose of sharing experiences and information about self-care with others who have similar conditions, chronic diseases, or disabilities. Special efforts are being made by health care professionals to reach and motivate members of various cultural and socioeconomic groups concerning lifestyle and health practices. Stress, improper diet, lack of exercise, smoking, drugs, high-risk behaviors (including risky sexual practices), and poor hygiene are all lifestyle behaviors known to have a negative effect on health. Health care professionals are concerned with encouraging behavior that promotes health. The goal is to motivate people to make improvements in the way they live, to modify risky behaviors, and to adopt healthy behaviors.
Influences on Health Care Delivery The health care delivery system is rapidly changing as the population and its health care needs and expectations change. The shifting demographics of the population, the increase in chronic illnesses and disability, the greater emphasis on economics, and technological advances have resulted in changing emphases in health care delivery and in nursing.
Chapter 1 POPULATION DEMOGRAPHICS Changes in the population in general are affecting the need for and the delivery of health care. The 2000 U.S. census data indicated that there were 281,421,906 people in the country (PluvioseFenton, 2001). This population expansion is attributed in part to improved public health services and improved nutrition. Not only is the population increasing, but the composition of the population is also changing. The decline in birth rate and the increase in life span attributed to improved health care have resulted in fewer school-age children and more senior citizens, most of whom are women. Much of the population resides in highly congested urban areas, with a steady migration of minority groups to the inner cities and a migration of middle-class people to suburban areas. The number of homeless people, including entire families, has increased significantly. The population has become more culturally diverse as increasing numbers of people from different national backgrounds enter the country. Because of such population changes, the need for health care for specific age groups, for women, and for a diverse group of people within specific geographic locations is altering the effectiveness of traditional means of providing health care and is necessitating far-reaching changes in the overall health care delivery system.
Aging Population The elderly population in the United States has increased significantly and will continue to grow in future years. In 1999, the nation’s 34.5 million adults older than 65 years of age constituted 12.7% of the population, with a ratio of 141 older women to 100 older men. The number of people in the United States older than 65 years of age is expected to reach 20% of the population by the year 2030. In addition, persons age 85 years and older constitute one of the fastest-growing segments of the population. According to the U.S. Bureau of the Census (2000), the number of people age 65 to 74 years was 8 times larger in 1999 than in 1900, and the number of people age 75 to 84 years was 16 times larger— but the number of people age 85 years and older was 34 times larger in 1999 than in 1900. Many elderly people suffer from multiple chronic conditions that are exacerbated by acute episodes. Elderly women, whose conditions are frequently underdiagnosed and undertreated, are of particular concern. There are approximately three women for every two men in the older population, and elderly women are expected to continue to outnumber elderly men. The health care needs of older adults are complex and demand significant investments, both professional and financial, by the health care industry.
Cultural Diversity An appreciation for the diverse characteristics and needs of individuals from varied ethnic and cultural backgrounds is important in health care and nursing. Some projections indicate that by 2030 racial and ethnic minority groups will comprise 40% of the population of the United States (Gooden, Porter, Gonzalez, & Mims, 2000). With increased immigration, both legal and illegal, this figure could easily increase to more than 50% by the year 2030 or even earlier. As the cultural composition of the population changes, it becomes increasingly important to address cultural considerations in the delivery of health care. Patients from diverse sociocultural groups bring to the health care setting different health care beliefs, values, and practices, as well as different risk factors for some disease conditions and unique reactions to treat-
Health Care Delivery and Nursing Practice
7
ment. These factors significantly affect the way an individual responds to health care problems or illness, to those who provide the care, and to the care itself. Unless these factors are understood and respected by health care providers, the care delivered may be ineffective and health care outcomes may be negatively affected. Culture is defined as learned patterns of behavior, beliefs, and values that can be attributed to a particular group of people. Included among the many characteristics that distinguish cultural groups are the manner of dress, language spoken, values, rules or norms of behavior, gender-specific practices, economics, politics, law and social control, artifacts, technology, dietary practices, and health beliefs and practices. Health promotion, illness prevention, causes of sickness, treatment, coping, caring, dying, and death are part of the healthrelated component of every culture. Every person has a unique belief and value system that has been shaped at least in part by his or her cultural environment. This belief and value system is very important and guides the individual’s thinking, decisions, and actions. It provides direction for interpreting and responding to illness and to health care. To promote an effective nurse–patient relationship and positive outcomes of care, nursing care must be culturally competent, appropriate, and sensitive to cultural differences. All attempts should be made to help the individual retain his or her unique cultural characteristics. Providing special foods that have significance and arranging for special religious observances may enable the patient to maintain a feeling of wholeness at a time when he or she may feel isolated from family and community. Knowing the cultural and social significance that particular situations have for each patient helps the nurse avoid imposing a personal value system when the patient has a different point of view. In most cases, cooperation with the plan of care is greatest when communication among the nurse, the patient, and the patient’s family is directed toward understanding the situation or the problem and respecting each other’s goals.
CHANGING PATTERNS OF DISEASE During the past 50 years, the health problems of the American people have changed significantly. Many infectious diseases have been controlled or eradicated; others, such as tuberculosis, acquired immunodeficiency syndrome (AIDS), and sexually transmitted diseases, are on the rise. An increasing number of infectious agents are becoming resistant to antibiotic therapy as a result of widespread inappropriate use of antibiotics. Therefore, conditions that were once easily treated have become complex and more life-threatening than ever before. The chronicity of illnesses and disability is increasing because of the lengthening life span of Americans and the expansion of successful treatment options for conditions such as cancer, human immunodeficiency virus (HIV) infection, and spina bifida; many people with these conditions live decades longer than in earlier years. Chronically ill people are the largest group of health care consumers in the United States (Davis & Magilvy, 2000). Because the majority of health problems seen today are chronic in nature, many people are learning to protect and maximize their health within the constraints of chronic illness and disability. As chronic conditions increase, health care broadens from a focus on cure and eradication of disease to include the prevention or rapid treatment of exacerbations of chronic conditions. Nursing, which has always encouraged patients to take control of their conditions, plays a prominent role in the current focus on management of chronic illness and disability.
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Unit 1
BASIC CONCEPTS IN NURSING PRACTICE
ADVANCES IN TECHNOLOGY AND GENETICS Advances in technology and genetics have occurred with greater frequency during the past several decades than in all other periods of civilization. Sophisticated techniques and devices have revolutionized surgery and diagnostic testing, making it possible to perform many procedures and tests on an outpatient basis. Increased knowledge and understanding of genetics has resulted in expanded screening, diagnostic testing, and treatments for a variety of conditions. This is also an era of sophisticated communication systems that connect most parts of the world, with the capability of rapid storage, retrieval, and dissemination of information. Such scientific and technological advances are themselves stimulating brisk change as well as swift obsolescence in health care delivery strategies. The advances in technology and genetics have raised many ethical issues for the health care system, health care providers, and society.
ECONOMIC CHANGES The philosophy that comprehensive, quality health care should be provided for all citizens prompted governmental concern about spiraling health care costs and wide variations in charges among providers. These concerns led to the Medicare prospective payment system (PPS) and the use of diagnosis-related groups (DRGs). In 1983, the U.S. Congress passed the most significant health legislation since the Medicare program was enacted in 1965. The government was no longer able to afford to reimburse hospitals for patient care that was delivered without any defined limits or costs. Therefore, it approved a PPS for hospital inpatient services. This system of reimbursement, based on DRGs, set the rates for Medicare payments for hospital services. Hospitals receive payment at a fixed rate for patients with diagnoses that fall into a specific DRG. A fixed payment has been predetermined for more than 470 possible diagnostic categories, covering the majority of medical diagnoses of all patients admitted to the hospital. Hospitals receive the same payment for every patient with a given diagnosis or DRG. If the cost of the patient’s care is lower than the payment, the hospital gains a profit; if the cost is higher, the hospital incurs a loss. As a result, hospitals now place greater emphasis on reducing costs, utilization of services, and length of patient stay. In addition, the Balanced Budget Act of 1997 added new rate requirements for ambulatory payment classifications (APCs) to hospitals and other providers of ambulatory care services. These providers must evaluate all services provided with greater efforts toward cost-effectiveness and reduction of costs. To qualify for Medicare reimbursement, care providers and hospitals must contract with peer review organizations (PROs) to perform quality and utilization review. The PROs monitor admission patterns, lengths of stay, transfers, and the quality of services and validate the DRG coding. The DRG system has provided hospitals with an incentive to cut costs and discharge patients as quickly as possible. Nurses in hospitals now care for patients who are older and sicker and require more nursing services; nurses in the community are caring for patients who have been discharged earlier and need acute care services with high-technology and long-term care. The importance of an effective discharge planning program, along with utilization review and a quality improvement program, is unquestionable. Nurses in acute care settings must assume responsibility with other health care team members for
maintaining quality care while facing pressures to discharge patients and decrease staffing costs. These nurses must also work with nurses in community settings to ensure continuity of care.
DEMAND FOR QUALITY CARE The general public has become increasingly interested in and knowledgeable about health care and health promotion. This awareness has been stimulated by television, newspapers, magazines, and other communications media and by political debate. The public has become more health conscious and has in general begun to subscribe strongly to the belief that health and quality health care constitute a basic right, rather than a privilege for a chosen few. In 1977, the National League for Nursing (NLN) issued a statement on nurses’ responsibility to uphold patients’ rights. The statement addressed patients’ rights to privacy, confidentiality, informed participation, self-determination, and access to health records. This statement also indicated ways in which respect for patients’ rights and a commitment to safeguarding them could be incorporated into nursing education programs and upheld and reinforced by those in nursing service. Nurses can directly involve themselves in ensuring specific rights, or they can make their influence felt indirectly (NLN, 1977). The ANA has worked diligently to promote the delivery of quality health and nursing care. Efforts by the ANA range from assessing the quality of health care provided to the public in these changing times to lobbying legislators to pass bills related to issues such as health insurance or length of hospital stay for new mothers. Legislative changes have promoted both delivery of quality health care and increased access by the public to this care. The National Health Planning and Resources Act of 1974 emphasized the need for planning and providing quality health care for all Americans through coordinated health services, staffing, and facilities at the national, state, and local levels. Medically underserved populations were the target for the primary care services provided for by this act. By the passage of bills supporting health insurance reform, barring discrimination against individuals with preexisting conditions, and expanding the portability of health care coverage, Congress has acknowledged the needs of consumers for adequate health insurance in this time of longer life spans and chronic illnesses. Efforts in some states to provide full health care coverage for citizens, particularly children, represent measures by state governments to promote access to health care. Legislative support of advanced practice nurses in individual practice is a recognition of the contribution of nursing to the health of consumers, particularly underserved populations.
Quality Improvement and Evidence-Based Practice In the 1980s, hospitals and other health care agencies implemented ongoing quality assurance (QA) programs. These programs were required for reimbursement for services and for accreditation by the Joint Commission on Accreditation of Healthcare Organizations (JCAHO). QA programs sought to establish accountability on the part of the health professions to society for the quality, appropriateness, and cost of health services provided. The JCAHO developed a generic model that required monitoring and evaluation of quality and appropriateness of care. The model was implemented in health care institutions and agencies through organization-wide QA programs and reporting systems.
Chapter 1 Many aspects of the programs were centralized in a QA department. In addition, each patient care and patient services department was responsible for developing its own plan for monitoring and evaluation. Objective and measurable indicators were used to monitor, evaluate, and communicate the quality and appropriateness of care delivered. In the early 1990s, it was recognized that quality of care as defined by regulatory agencies continued to be difficult to measure. QA criteria were identified as measures to ensure minimal expectations only; they did not provide mechanisms for identifying causes of problems or for determining systems or processes that need improvement. Continuous quality improvement (CQI) was identified as a more effective mechanism for improving the quality of health care. In 1992, the revised standards of the JCAHO mandated that health care organizations implement a CQI program. Recent amendments to JCAHO standards have specified that patients have the right to care that is considerate and preserves dignity; that respects cultural, psychosocial, and spiritual values; and that is age specific (Krozok & Scoggins, 2001). Quality improvement efforts have focused on ensuring that the care provided meets or exceeds JCAHO standards. Unlike QA, which focuses on individual incidents or errors and minimal expectations, CQI focuses on the processes used to provide care, with the aim of improving quality by assessing and improving those interrelated processes that most affect patient care outcomes and patient satisfaction. CQI involves analyzing, understanding, and improving clinical, financial, or operational processes. Problems identified as more than isolated events are analyzed, and all issues that may affect the outcome are studied. The main focus is on the processes that affect quality. As health care agencies continue to implement CQI, nurses have many opportunities to be involved in quality improvement. One such opportunity is through facilitation of evidence-based practice. Evidence-based practice—identifying and evaluating current literature and research and incorporating the findings into care guidelines—has been designated as a means of ensuring quality care. Evidence-based practice includes the use of outcome assessment and standardized plans of care such as clinical guidelines, clinical pathways, or algorithms. Many of these measures are being implemented by nurses, particularly by nurse managers and advanced practice nurses. Nurses directly involved in the delivery of care are engaged in analyzing current data and refining the processes used in CQI. Their knowledge of the processes and conditions that affect patient care is critical in designing changes to improve the quality of the care provided.
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A case manager often facilitates and coordinates interventions to ensure that the patient progresses through the key events and achieves the desired outcomes. Nurses providing direct care have an important role in the development and use of clinical pathways through their participation in researching the literature and then developing, piloting, implementing, and revising clinical pathways. In addition, nurses monitor outcome achievement and document and analyze variances. Figure 1-2 presents an example of a clinical pathway. Other examples of clinical pathways can be found in Appendix A. Care mapping, multidisciplinary action plans (MAPs), clinical guidelines, and algorithms are other evidence-based practice tools that are used for interdisciplinary care planning. These tools are used to move patients toward predetermined outcome markers using phases and stages of the disease or condition. Algorithms are used more often in an acute situation to determine a particular treatment based on patient information or response. Care maps, clinical guidelines, and MAPs (the most detailed of all tools) provide coordination of care and education through hospitalization and after discharge (Cesta & Falter, 1999). Because care mapping and guidelines are used for conditions in which the patient’s progression often defies prediction, specific time frames for achieving outcomes are excluded. Patients with highly complex conditions or multiple underlying illnesses may benefit more from care mapping or guidelines than from clinical pathways, because the use of outcome markers (rather than specific time frames) is more realistic in such cases. Through case management and the use of clinical pathways or care mapping, patients and the care they receive are continually assessed from preadmission to discharge—and in many cases after discharge in the home care and community settings. These tools are used in hospitals and alternative health care delivery systems to facilitate the effective and efficient care of large groups of patients. The resultant continuity of care, effective utilization of services, and cost containment are expected to be major benefits for society and for the health care system.
ALTERNATIVE HEALTH CARE DELIVERY SYSTEMS The rising cost of health care over the last few decades has led to the use of managed health care and alternative health care delivery systems, including health maintenance organizations (HMOs) and preferred provider organizations (PPOs).
Managed Care Clinical Pathways and Care Mapping Many hospitals, managed care facilities, and home health services nationwide use clinical pathways or care mapping to coordinate care for a caseload of patients (Klenner, 2000). Clinical pathways serve as an interdisciplinary care plan and as the tool for tracking a patient’s progress toward achieving positive outcomes within specified time frames. Clinical pathways have been developed for certain DRGs (eg, open heart surgery, pneumonia with comorbidity, fractured hip), for high-risk patients (eg, those receiving chemotherapy), and for patients with certain common health problems (eg, diabetes, chronic pain). Using current literature and expertise, pathways identify best care. The pathway indicates key events, such as diagnostic tests, treatments, activities, medications, consultation, and education, that must occur within specified times for the patient to achieve the desired and timely outcomes.
The PPS has given rise to a much broader pattern of reimbursement and cost control: managed health care. Managed care is an important trend in health care. The failure of the regulatory efforts of past decades to cut costs and the escalation of health care costs to 15% to 22% of the gross domestic product have prompted business, labor, and government to assume greater control over the financing and delivery of health care. The common features that characterize managed care include prenegotiated payment rates, mandatory precertification, utilization review, limited choice of provider, and fixed-price reimbursement. The scope of managed care has expanded from inhospital services; to HMOs or variations such as PPOs; to various ambulatory, long-term, and home care services, as well as related diagnostic and therapeutic services. Over time there has been a significant expansion of managed health care to the point that distinctions among different providers—including HMOs, (text continues on page 14)
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____ ____ ____ ____
____ ____ ____ ____
IV antibiotics given Ice pack to surgical site Pain control: ❑ Spinal ❑ Epidural ❑ PCA Patient reported pain level ≤ 3 (0–10)______
____________________________
____ ____ Diet advanced and tolerated
NUTRITION
Transfusion given if ordered ❑ AB ❑ BB ❑ DD # of transfusions __________________________________ ____ ____ ____ IV Antibiotics completed ____ ____ ____ ❑ Spinal ❑ Epidural ❑ PCA discontinued ____ ____ ____ Patient reported pain level ≤ 3 (0–10)____
PAIN CONTROL/MEDICATION
TESTS/LABS
(continued)
____ ____ ____ No nausea or vomiting, usual diet
Offer oral meds for pain 30 minutes before therapy prn ____ ____ ____ Patient reported pain level ≤ 3 (0–10)______
____ H&H ≥ 9/26 ___________________________________ ____ Other: _______________________________________ ____ Final T/K Revision cultures without growth
____ ____ ____ ____
H&H ≥ 9/26 ___________________________________ Chem 7 WNL T/K Revision cultures no growth Other: _______________________________________
____AM care completed ____ ____ ____ VS Q4h ____ ____ ____ ____ VS normal, temp .05) levels of treatment intensity, many more types of treatments and number of treatments, and more difficulties with health care professionals. It was further reported by the women that the interpersonal and relational facets of their illnesses were more stressful and were the most difficult aspects of having cancer. Men indicated that their stress was associated with the work role and loss of finances. Nursing Implications Some women find the experience of cancer treatment to be very difficult. The intensity of the treatment may place women at risk for development of PTSD. Overall, women need support from health care professionals, additional control over their treatment, opportunity to tell their stories and concerns, support groups, and access to complementary therapies. Having psychosocial resources available could assist in the prevention of, assessment for, and interventions with patients encountering cancer-related PTSD.
Clinical depression is distinguished from everyday feelings of sadness by its duration and severity. Most people occasionally feel down or depressed, but these feelings are short-lived and do not result in impaired functioning. Clinically depressed people usually have had signs of a depressed mood or a decreased interest in pleasurable activities for at least a 2-week period. An obvious impairment in social, occupational, and overall daily functioning occurs in some people. Others function appropriately in their interactions with the outside world by exerting great effort and forcing themselves to mask their distress. Sometimes they are successful at camouflaging their depression for months or years and astonish family members and others when they finally succumb to the problem. Many people experience depression but seek treatment for somatic complaints. The leading somatic complaints of patients struggling with depression are headache, backache, abdominal
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Chart 7-9
BIOPHYSICAL AND PSYCHOSOCIAL CONCEPTS IN NURSING PRACTICE
• ASSESSMENT
Assessing Physiologic and Psychological Indicators of PTSD Physiologic Indicators Dilated pupils Headaches Sleep pattern disturbances Tremors Elevated blood pressure Tachycardia or palpitations Diaphoresis with cold, clammy skin Hyperventilation Dyspnea Smothering or choking sensation Nausea, vomiting, or diarrhea Stomach ulcers Dry mouth Abdominal pain Muscle tension or soreness Exhaustion Psychological Indicators Anxiety Anger Depression Fears or phobias Survivor guilt Hypervigilance Nightmares or flashbacks Intrusive thoughts about the trauma Impaired memory Dissociative states Restlessness or irritability Strong startle response Substance abuse Self-hatred Feelings of estrangement Feelings of helplessness, hopelessness, or powerlessness Lack of interest in life Inability to concentrate Difficulty communicating, caring, and expressing love Problems with relationships Sexual problems ranging from acting out to impotence Difficulty with intimacy Inability to trust Lack of impulse control Aggressive, abusive, or violent behavior, including suicide Thrill-seeking behaviors Copel, L. C. (2000). Nurse’s clinical guide: Psychiatric and mental health care (2nd ed.). Springhouse, PA: Springhouse.
pain, fatigue, malaise, anxiety, and decreased desire or problems with sexual functioning (Stuart & Laraia, 2000). These sensations are frequently manifestations of depression. The depression is undiagnosed about half of the time and masquerades as physical health problems (Carson, 1999). People with depression also exhibit poor functioning and high rates of absenteeism from work and school. Specific symptoms of clinical depression include feelings of sadness, worthlessness, fatigue, and guilt and difficulty concentrating or making decisions. Changes in appetite, weight gain or loss, sleep disturbances, and psychomotor retardation or agitation are also common. Often, patients have recurrent thoughts
about death or suicide or have made suicide attempts (American Psychiatric Association, 2000). A diagnosis of clinical depression is made when a person presents with at least five of nine diagnostic criteria for depression. Chart 7-10 lists these criteria (American Psychiatric Association, 2000). Unfortunately, only one of three depressed people is properly diagnosed and appropriately treated. In the United States, about 15% of severely depressed people commit suicide, and two-thirds of patients who have committed suicide had been seen by health care practitioners during the month before their death (National Institute of Mental Health, 1999). When patients make statements that are self-deprecating, express feelings of failure, or are convinced that things are hopeless and will not improve, they may be at risk for suicide. Risk factors for suicide include the following:
• Age younger than 20 or older than 45 years, especially older than 65 years
• Gender—women make more attempts, men are more successful
• Dysfunctional family—members have experienced cumu• • • • • • • • •
lative multiple losses and possess limited coping skills Family history of suicide Severe depression Severe, intractable pain Chronic, debilitating medical problems Substance abuse Severe anxiety Overwhelming problems Severe alteration in self-esteem or body image Lethal suicide plan
NURSING IMPLICATIONS Because any loss in function, change in role, or alteration in body image is a possible antecedent to depression, nurses in all settings encounter patients who are depressed or who have thought about suicide. Depression is suspected if changes in the patient’s thoughts or feelings and a loss of self-esteem are noted. See Chart 7-11 for a list of risk factors for depression. Depression can occur at any age, and it is diagnosed more frequently in women than in men. For elderly patients, the nurse should be aware that decreased mental alertness and withdrawal-type responses may be indicative of de-
Chart 7-10
Diagnostic Criteria for Depression Based on the DSM-IV TR
A person experiences at least five out of nine characteristics, with one of the first two symptoms present most of the time. 1. Depressed mood 2. Loss of pleasure or interest 3. Weight gain or loss 4. Sleeping difficulties 5. Psychomotor agitation or retardation 6. Fatigue 7. Feeling worthless 8. Inability to concentrate 9. Thoughts of suicide or death American Psychiatric Association. (2000). Diagnostic and statistical manual of mental disorders (DSM IV-TR) (4th ed.). Washington, DC: Author.
Chapter 7
Chart 7-11
Risk Factors for Depression Family history Stressful situations Female gender Prior episodes of depression Onset before age 40 years Medical comorbidity Past suicide attempts Lack of support systems History of physical or sexual abuse Current substance abuse
pression. Consultation with the psychiatric liaison nurse to assess and differentiate between dementia-like symptoms and depression is often helpful. For all patients, talking about their fears, frustration, anger, and despair can help alleviate a sense of helplessness and facilitate the process of obtaining the necessary treatment. Helping patients learn to cope effectively with conflict, interpersonal problems, and grief, and encouraging patients to discuss actual and potential losses may hasten their recovery from depression. Patients can also be helped to identify and decrease negative self-talk and unrealistic expectations and shown how negative thinking contributes to depression. Because physical health and self-care activities are adversely affected by depression, nurses should monitor patients for the onset of new problems. All patients with depression should be evaluated to determine whether they would benefit from antidepressant therapy. In addition to the measures cited previously for helping patients manage depression, research studies indicate a reduction in distress when anxiety and depression are treated with psychoeducational programs, the establishment of support systems, and counseling (Devine & Westlake, 1995). Referrals to psychoeducational programs can be instrumental in helping patients and their families understand depression, treatment options, and coping strategies. (In crisis situations, it is better to refer the patient to a psychiatrist, psychiatric nurse specialist, or crisis center.) Explaining to patients that depression is a medical illness and not a sign of personal weakness, and that effective treatment will allow them to feel better and stay emotionally healthy, is an important aspect of care (Stuart & Laraia, 2000).
Substance Abuse Some people use mood-altering substances in an attempt to cope with life’s challenges. A person who abuses substances has an inability to make healthy decisions and to solve problems effectively. Typically, people who abuse substances are unable to identify and implement adaptive behaviors and use illegally obtained drugs, prescribed or over-the-counter medications, and alcohol alone or in combination with other drugs in an ineffective attempt to cope with the pressures, strains, and burdens of life. Over time, physiologic, emotional, cognitive, and behavioral problems develop as a result of continuous substance use. These problems cause distress for the individual, the family, and the community. Some people may respond to personal illness or the illness of a loved one by using substances to decrease emotional pain.
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NURSING IMPLICATIONS Substance abuse is encountered in all clinical settings. Intoxication and withdrawal are two common substance abuse problems. Often, the nurse sees patients who have experienced trauma as a result of inebriation. Other patients who are active substance abusers enter the primary care setting with a diagnosis other than that of substance abuse. Many do not disclose the extent of their substance use. The patient’s use of denial or lack of knowledge about the devastating effects of psychoactive substances can be detected by the nurse who performs a substance use assessment (Chart 7-12). In addition, the nurse can incorporate tools into the assessment that enable drug use to be detected. Examples of such instruments are the CAGE Questionnaire (Ewing, 1984), the Michigan Alcohol Screening Test (Selzer, 1971), and the Addiction Severity Index (McLellan, Kushner, Metzger, & Peters, 1992). The CAGE Questions Adapted to Include Drugs (CAGEAID) is presented in Chapter 5, Chart 5-2. Health professionals are in pivotal positions for identifying a substance abuse problem, instituting treatment protocols, and making follow-up referrals. Because substance abuse severely affects the family, the nurse helps the family members confront the situation, decrease their enabling behaviors, and motivate the person to obtain treatment. Caring for codependent family members is another nursing priority. A codependent person tends to manifest unhealthy patterns in relationships with others. Codependents struggle with a need to be needed, an urge to control others, and a willingness to remain involved and suffer with a person who has a drug problem. The family may approach the health care team to help set limits on the dysfunctional behavior of a person who abuses substances. At these times, a therapeutic intervention is organized for the purpose of confronting the patient about substance use and the need to obtain drug or alcohol treatment. The nurse or other knowledgeable addiction counselor helps the family present the addicted person with a realistic perspective about the problem, their concerns about and caring for the person, and a specific plan for treatment. This therapeutic intervention works on the premise that honest and caring confrontation can break through the person’s denial of the addiction. If the person refuses to participate in the designed plan, the family members define the consequences and state their commitment to follow through with them. This intervention is empowering to the family and usually provides the structure needed to secure treatment. Even with treatment, however, patients may experience relapse. Nurses work with patients and their families to prevent relapse and to be prepared if relapse occurs. Relapse is considered a
Chart 7-12
• ASSESSMENT
Assessing Substance Abuse • • • • • • • • •
Past and recurrent use of the substance Patient’s view of substance use as a problem Age when first used and last used substance Length and duration of use of substance Preferred method of use of substance Amount of substance used How substance is procured Effect of or reaction to substance All attempts to cease or decrease substance use
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part of the illness process and therefore must be viewed and addressed in the same way that chronic illness is treated. The nurse who is working with a patient and family struggling with an addiction must dispel the myth that addiction is a defect in character or a moral fault. Views on substance abuse vary within our society. A person’s background may help determine whether he or she uses drugs, what drugs are used, and when they are used (Copel, 2000). The combination of variables, such as values and beliefs, family and personal norms, spiritual convictions, and conditions of the current social environment, predisposes a person to the possibility of drug use, motivation for treatment, and continual recovery (Copel, 2000). It has also been said that a person’s attitude, especially toward alcohol, reflects the overall beliefs and attitudes of that individual’s culture (Giger & Davidhizer, 1999).
Loss and Grief Loss is a part of the life cycle. All people experience loss in the form of change, growth, and transition. The experience of loss is painful, frightening, and lonely, and it triggers an array of emotional responses (Chart 7-13). People may vacillate between denial, shock, disbelief, anger, inertia, intense yearning, loneliness, sadness, loss of control, depression, and spiritual despair (Brewster, 1999). In addition to normal losses associated with life cycle stages there are the potential losses of health, a body part, self-image, self-esteem, and even one’s life. When loss is not acknowledged or there are multiple losses, anxiety, depression, and health problems may occur. Likewise, people with physical health problems, such as diabetes mellitus, acquired immunodeficiency syndrome
(AIDS), cardiac conditions, gastrointestinal disorders, disabilities, and neurologic impairments, tend to respond to these illnesses with feelings of grief. People grieve in different ways, and there is no time line for completing the grief process. The time of grieving often depends on the significance of the loss, the length of time the person was known and loved, the anticipation of or preparation for the loss, the person’s emotional stability and maturity, and the person’s coping ability (Arnold & Boggs, 1999). Regardless of the duration of the grieving process, there are two basic goals: (1) healing the self, and (2) recovering from the loss. Other factors that influence grieving are the type of loss, life experiences with various changes and transitions, religious beliefs, cultural background, and personality type (Kemp, 2000). Some patients may resort to abuse of prescription medications, illegal drugs, or alcohol if they find it difficult to cope with the loss; the grief process is then complicated by the use of addictive substances.
NURSING IMPLICATIONS Nurses identify patients and family members who are grieving and work with them to accomplish the four major tasks of the grief process: (1) acceptance of the loss, (2) acknowledgment of the intensity of the pain, (3) adaptation to life after the loss, and (4) cultivation of new relationships and activities (Worden, 1982). Chart 7-14 outlines nursing care activities useful for those who are bereaved. Another responsibility of the nurse is to assess and differentiate between grief and depression by knowing the common thoughts, feelings, physical or bodily reactions, and behaviors associated with grief compared with depression (see Chart 7-14). The physical response to grief includes the sensation of somatic distress, a tightness in the throat followed by a choking sensation or shortness of breath, the need to sigh, an empty feeling inside the abdomen, lack of muscle power, and intense disabling distress. Grief can further debilitate an already compromised patient and can have a strong impact on family functioning.
Chart 7-14
Caring for the Bereaved
• Have contact physically (with the patient’s permission) and • • • • • • • • • • • • • •
emotionally with the person. Assess where the person is in the grieving process. Demonstrate genuine compassion and caring. Give permission to grieve and normalize the grieving process. Mention the loss or the deceased person’s name. Encourage the person to talk about the relationship he or she had with the deceased person. Understand that people need to talk about the events and feelings around the death and will repeat themselves. Tell the person to expect mood swings, pain, and various life changes. Focus on clarifying and using coping skills. Allow the person to take a break from grieving and focus on self-care. Encourage sources of comfort such as religion or nature. Identify secondary losses and unfinished business. Acknowledge that there will be eventual recovery. Discuss the anniversary phenomenon. Encourage medical or psychiatric care as needed.
Chapter 7
Death and Dying Coping with death, one’s own or a loved one’s, is considered the ultimate challenge. The idea of death is threatening and anxietyprovoking to many people. Kubler-Ross (1975, p. 1) stated, “The key to the question of death unlocks the door of life. . . . For those who seek to understand it, death is a highly creative force.” Common fears of dying people are fear of the unknown, pain, suffering, loneliness, loss of the body, and loss of personal control. In recent years, the process of dying has changed as advances have been made in the care of chronically and terminally ill patients. Technological innovations and modern therapeutic treatments have prolonged the life span, and many deaths are now the result of chronic illnesses that result in physiologic deterioration and subsequent multisystem failure. Preparation for an impending death can precipitate the experience of anticipatory grieving. Although anticipatory grief can have positive effects on later grief, this does not hold true for all people. For some family members, anticipatory grief is seen as a risk factor for poor early bereavement adjustment (Levy, 1991). The nurse must be aware of the uniqueness and individuality inherent in the grieving process and work to meet the needs of those involved in the best way possible.
DEATH AND DYING FRAMEWORKS Various frameworks for understanding the concept of grief and the stages of death and dying may be useful to the nurse. The stages of bereavement described by Bowlby (1961) are protest, disorganization, and reorganization. Kubler-Ross (1975) conceptualized five stages of grieving: denial, anger, bargaining, depression, and acceptance. Often, the dying person and the survivors do not experience these responses in an orderly or linear fashion; rather, there is random movement between all the stages for differing periods of time. Another model for successful grieving, proposed by Engel (1964), is shock and disbelief, development of awareness, and restitution. The themes common to almost all models of grieving are periods of avoidance, confrontation, and acceptance (Cooley, 1992). Another framework for understanding the individuality of the dying process is provided by the “patterns of living while dying” described by Martocchio (1982). There are four identified patterns of living based on the clinical trajectories of dying people. The first is referred to as peaks and valleys or periods of hope and periods of depression. Despite the hopeful times, there is still an overall movement toward decline and death. The second pattern is one described as distinct but descending plateaus. This course also reflects a downward trend with progressive debilitation and eventual death. The third pattern is a clear downward slope with many physiologic parameters indicating that death is imminent. This pattern is often observed in the critical care unit when people and families have no time to prepare for the death. The last pattern is a downward slant that reveals a crisis event, such as a severe cerebral hemorrhage with almost no hope of recovery. Often, a patient in this pattern is being maintained on life support systems. The nurse should recognize that a person may experience one or more of these living–dying patterns.
NURSING IMPLICATIONS Nursing care involves providing comfort, maintaining safety, addressing physical and emotional needs, and teaching coping strategies to terminally ill patients and their families. More than ever, the nurse must explain what is happening to the patient and
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the family and be a confidante who listens to them talk about dying. Hospice care, attention to family and individual psychosocial issues, and symptom and pain management are all part of the nurse’s responsibilities. The nurse must also be concerned with ethical considerations and quality-of-life issues that affect dying people. Of utmost importance to the patient is assistance with the transition from living to dying, maintaining and sustaining relationships, finishing well with the family, and accomplishing what needs to be said and done. The nurse is the consistent link in promoting understanding of the patient’s disease and the dying process and in making the event more manageable for the patient and family, who will require assistance to resolve problems and proceed through the grief work. Retaining as much control as possible during the process of dying allows the patient and family to make as much sense as possible out of an overwhelming situation. In the hospital, in long-term care facilities, and in home settings, the nurse explores choices and end-of-life decisions with the patient and family. Referrals to home care and hospice services, as well as specific referrals appropriate for the management of the situation, are initiated. The nurse is also an advocate for the dying person and works to uphold that person’s rights. The use of living wills and advance directives allows the patient to exercise the right to have a “good” death or to die with dignity. Additional information about endof-life care is presented in Chapter 17.
Spirituality and Spiritual Distress Spirituality is defined as connectedness with self, others, a life force, or God that allows people to experience self-transcendence and find meaning in life. Spirituality helps people discover a purpose in life, understand the vicissitudes of life, and develop their relationship with God or a Higher Power. Within the framework of spirituality, a person discovers truths about the self, about the world, and about concepts such as love, compassion, wisdom, honesty, commitment, imagination, reverence, and morality. Often, spiritual behavior is expressed through sacrifice, self-discipline, and spending time in activities that focus on the inner self or the soul. Religion and nature are two vehicles that people use to connect themselves with God or a Higher Power; however, bonds to religious institutions, beliefs, or dogma are not required to experience the spiritual sense of self. Faith, considered the foundation of spirituality, is a belief in something that a person cannot see (Carson, 1999). The spiritual part of a person views life as a mystery that unfolds over the lifetime, encompassing questions about meaning, hope, relatedness to God, acceptance or forgiveness, and transcendence (Byrd, 1999; Sheldon, 2000; Sussman, Nezami, & Mishra, 1997). A strong sense of spirituality or religious faith can have a positive impact on health (Dunn & Horgas, 2000; Kendrick & Robinson, 2000; Matthews & Larson, 1995). Spirituality is also a component of hope, and, especially during chronic, serious, or terminal illness, patients and their families often find comfort and emotional strength in their religious traditions or spiritual beliefs. At other times, illness and loss can cause a loss of faith or meaning in life and a spiritual crisis. The nursing diagnosis of spiritual distress is applicable to those who have a disturbance in the belief or value system that provides strength, hope, and meaning in life.
NURSING IMPLICATIONS Spiritually distressed patients (or family members) may show despair, discouragement, ambivalence, detachment, anger, resentment, or fear. They may question the meaning of suffering, life,
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and death, and express a sense of emptiness. The nurse assesses spiritual strength by inquiring about the person’s sense of spiritual well-being, hope, and peacefulness. Have spiritual beliefs and values changed in response to illness or loss? The nurse assesses current and past participation in religious or spiritual practices and notes the patient’s response to questions about spiritual needs— grief, anger, guilt, depression, doubt, anxiety, or calmness—to help determine the patient’s need for spiritual care. Another simple assessment technique is to inquire about the patient’s and family’s desire for spiritual support. For nurses to provide spiritual care, they must be open to being present and supportive when patients experience doubt, fearfulness, suffering, despair, or other difficult psychological states of being. Interventions that foster spiritual growth or reconciliation include being fully present; listening actively; conveying a sense of caring, respect, and acceptance; using therapeutic communication techniques to encourage expression; suggesting the use of prayer, meditation, or imagery; and facilitating contact with spiritual leaders or performance of spiritual rituals (Sumner, 1998; Sussman, 2000). Patients with serious, chronic, or terminal illnesses face physical and emotional losses that threaten their spiritual integrity. During acute and chronic illness, rehabilitation, or the dying process, spiritual support can stimulate patients to regain or strengthen their connections with their inner selves, their loved ones, and their God or Higher Power to transcend suffering and find meaning. Nurses can alleviate distress and suffering and enhance wellness by meeting their patients’ spiritual needs.
?
Critical Thinking Exercises
1.
A 55-year old man tells the nurse that he is not going to be a part of a clinical drug investigation. He states, “I may not get the drug. I may end up with a placebo. I’m going to try some alternative methods. I feel like traditional medicine is letting me down.” How does the nurse handle this situation? What assessment data need to be collected and discussed with other members of the health care team?
2.
The nurse is working with a family to develop therapeutic interventions for a family member who has a cocaine and alcohol addiction problem. One family member tells the nurse she will never be able to support the plan decided on by the rest of the family. How would you approach this person? What strategies would be useful for this person and for the entire family?
3.
The family of a man who is dying from lung cancer tells the hospice nurse that they are overwhelmed by the hopelessness of their father’s situation. What can the nurse do to provide guidance and find hope within terminal illness? How does the nurse assist this family to meet their emotional, social, and spiritual needs?
REFERENCES AND SELECTED READINGS Books Aiken, L. (2000). Dying, death, and bereavement (4th ed.). Mahwah, NJ: Lawerence Erlbaum. American Psychiatric Association. (2000). Diagnostic and statistical manual of mental disorders (DSM IV) (4th ed.). Washington, DC: Author.
Arnold, E., & Boggs, K. (1999). Interpersonal relationships: Professional communication skills for nurses (3rd ed.). Philadelphia: W. B. Saunders. Barry, P. D. (1998). Mental health and mental illness (6th ed.). Philadelphia: Lippincott-Raven. Bowlby, J. (1961). Attachment and loss (Vol. 1). New York: Basic Books. Boyd-Franklin, N., & Bry, B. H. (2001). Reaching out in family therapy. New York: Guilford Press. Brewster, S. (1999). To be an anchor in the storm: A guide for families and friends. New York: Sealpress. Burr, W., Klein, S., Burr, R., Doxey, C., Haeker, B., Holman, T., Martin, P., McClure, R., Parrish, S., Stuart, D., Taylor, A., & White, M. (1994). Reexamining family stress: New theory and research. Thousand Oaks, CA: Sage. Burr, W., et al. (1993). Family science. Pacific Grove, CA: Brooks/Cole. Carson, V. B. (1999). Mental health nursing: The nurse-patient journey (2nd ed.). St. Louis, MO: Mosby. Copel, L. C. (2000). Nurse’s clinical guide: Psychiatric and mental health care (2nd ed.). Springhouse, PA: Springhouse. Feldman, R. (2000). Development across the life span (2nd ed.). Upper Saddle River, NJ: Prentice Hall. Friedman, M. M. (1998). Family nursing: Research, theory, and practice (4th ed.). Stamford, CT: Appleton & Lange. Gelles, J. (1997). Intimate violence in families. Thousands Oaks, CA: Sage. Gelles, J., & Loseke, D. (Eds.) (1993). Current controversies on family violence. Newbury Park, CA: Sage. Giger, J. N., & Davidhizer, R. E. (1999). Transcultural nursing: Assessment and intervention (3rd ed.). St. Louis: C. V. Mosby. Keegan, L. (2001). Healing with complementary and alternative therapies. Albany, NY: Delmar. Kemp, C. (2000). Terminal illness. Philadelphia: Lippincott Williams & Wilkins. Kubler-Ross, E. (1975). Death: The final stage of growth. Englewood Cliffs, NJ: Prentice-Hall. Kuhn, M. A. (1999). Complementary therapies for health care providers. Philadelphia, Lippincott Williams & Wilkins. Luckmann, J. (1999). Transcultural communication in nursing. Albany, NY: Delmar. Martocchio, B. C. (1982). Living while dying. Bowie, MD: Robert J. Brady. Matthews, D. A., & Larson, D. B. (1995). The faith factor: An annotated bibliography of clinical research on spiritual subjects (Vol. 3). Rockville, MD: National Institute for Health Care Research. McCann, I. J., & Pearlman, L. A. (1990). Psychological trauma and the adult survivor. New York: Brunner/Mazel. McDowell, D. M., & Spitz, H. I. (1999). Substance abuse: From principles to practice. Philadelphia: Brunner/Mazel. Murray, R. B., & Zentner, J. P. (2001). Health assessment and promotion strategies through the life span (7th ed.). Stamford, CT: Appleton & Lange. Nowinski, J. K. (1998). Family recovery and substance abuse. Thousand Oaks, CA: Sage. Rice, F. P. (2001). Human development: A lifespan approach (4th ed.). Upper Saddle River, NJ: Prentice Hall. Rice, V. H. (Ed.). (2000). Handbook of stress, coping, and health: Implications for nursing research, theory, and practice. Thousand Oaks, CA: Sage. Roach, S. S., & Nieto, B. C. (1998). Healing and the grief process. Albany, NY: Delmar. Stanhope, M., & Lancaster, J. (1999). Community and public health nursing (7th ed.). St. Louis: C. V. Mosby. Stuart, G. W., & Laraia, M. T. (2000). Principles and practice of psychiatric nursing (7th ed.). St. Louis: C. V. Mosby. Tucker, J. A., Donovan, D. M., & Marlatt, G. A. (2001). Changing additive behavior. NY: Guilford. U.S. Department of Health & Human Services (1993). Clinical practice guidelines Agency for Health Care Policy and Research: Number 5. Depression in clinical care: Vol. 1. Detection and diagnosis. Rockville, MD: U.S. Government Printing Office.
Chapter 7 U.S. Department of Health & Human Services (1993). Clinical practice guidelines Agency for Health Care Policy and Research: Number 5. Depression in primary care: Vol. 2. Treatment of major depression. Rockville, MD: U.S. Government Printing Office. U.S. Department of Health & Human Services, Public Health Service, Agency for Health Care Policy and Research. (1993). Depression in primary care: Vol. 1. Detection and diagnosis. Clinical Practice Guideline. (AHCPR Publication No. 93-0550). Rockville, MD: U.S. Government Printing Office. U.S. Department of Health & Human Services, Public Health Service, Agency for Health Care Policy and Research. (1993) Depression in primary care: Vol. 2, Treatment of major depression. Clinical Practice Guideline. (AHCPR Publication No. 93-0551). Rockville, MD: U.S. Government Printing Office. U.S. Public Health Service (2000). Healthy people 2010: Understanding and improving health. Washington, DC: U.S. Government Printing Office. Worden, W. (1982). Grief counseling and grief therapy: A handbook for the mental health practitioner. New York: Springer Publishing. Wright, L. M., & Leahey, M. (2000). Nurses and families: A guide to family assessment and intervention. Philadelphia, PA: Davis.
Journals Asterisks indicate nursing research articles. General Cohen, S., & Herbert, T. (1996). Health psychology: Psychological factors and physical disease from the perspective of human psychoneuroimmunology. Annual Review of Psychology, 47, 113–142. Devine, E. C., & Westlake, S. K. (1995). The effects of psychoeducational care provided to adults with cancer: Metaanalysis of 116 studies. Oncology Nursing Forum, 22(9), 1369–1376. Eisenberg, D., Kessler, R., Foster, C., Norlock, F., Calkins, D., & Delbanco, T. (1993). Unconventional medicine in the United States: Prevalence, costs, and patterns of use. New England Journal of Medicine, 328, 246–252. Alternative Therapies Boutin, P. D., Buchwald, D., Robinson, L., & Collier, A. C. (2000). Use of alternative and complementary therapies among outpatients and physicians at a municipal hospital. Journal of Alternative and Complementary Medicine, 6(4), 353–343. Sparber, A., Wootton, J. C., Bauer, L., Curt, G., Eisenberg, D. M., Levin, T., & Steinberg, S. M. (2000). Use of complementary medicine by adult patients participating in HIV/AIDS clinical trials. Journal of Alternative and Complementary Medicine, 6(5), 415–422. Wolsho, P., Ware, L., Kutner, J., Lin, C., Albertson, G., Cyran, L., Schilling, L., & Anderson, R. J. (2000). Alternative/complementary medicine: Wider usage than generally appreciated. Journal of Alternative and Complementary Medicine, 6(4), 321–326. Wynia, M. K., Eisenberg, D. M., & Wilson, I. B. (1999). Physicianpatient communication about complementary and alternative medical therapies: A survey of physicians caring for patients with human immunodeficiency virus infection. Journal of Alternative and Complementary Medicine, 5(5), 447–456. Coping Backer, J. H. (2000). Stressors, social support, and coping and health dysfunction in individuals with Parkinson’s disease. Journal of Gerontological Nursing, 26(11), 6–16. Dzurec, L. C. (2000). Fatigue and relatedness in inordinately tired women. Journal of Gerontological Nursing, 32(4), 339–345. King, K. B., Zewic, J. J., Kimble, L. P., & Rowe, M. A. (1998). Optimism, coping, and long-term recovery from coronary artery surgery in women. Research in Nursing & Health, 21(1), 15–26. Morse, S. R., & Fife, B. (1998). Coping with a partner’s cancer: Adjustment at four stages of the illness trajectory. Oncology Nursing Forum, 25(4), 751–760. Schnoll, R. A., Harlow, L. L., & Brower, L. (2000). Spirituality, demographic and disease factors, and adjustment to cancer. Cancer Practice: A Multidisciplinary Journal of Cancer Care, 8(6), 298–304.
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Twibell, R. S. (1998). Family coping during critical illness. Dimensions in Critical Care Nursing, 17(2), 100–112. Depression Martin, A. C. (2000). Major depressive illness in women: Assessment and treatment in the primary care setting. Nurse Practitioner Forum, 11(3), 179–186. National Institute of Mental Health. (1992). Depression awareness, recognition, treatment fact sheet. DHHS Publication No. [ADM] 92-1680. Rockville, MD: Government Printing Office. Rasmussen, J. (2000). Treating depression: The continuing challenge of achieving long term recovery. Mental Health Care and Learning Disabilities, 3(9), 295–308. Rogers, J. C., & Holm, M. B. (2000). Daily living skills and habits of older women with depression. Occupational Therapy Journal of Research, 20(Suppl. 1), 68S–85S. Grief, Death, and Dying Conrad, N. L. (1985). Spiritual support for the dying. Nursing Clinics of North America, 20(2), 415–425. Cooley, M. E. (1992). Bereavement care: A role for nurses. Cancer Nursing, 15(2), 125–129. Fauri, D. P., Ettner, B., & Kovacs, P. T. (2000). Bereavement services in acute care settings. Death Studies, 24(1), 51–64. Engel, G. (1964). Grief and grieving. American Journal of Nursing, 64(7), 93–96. Hallgrinsdottir, E. M. (2000). Accident and emergency nurses’ perceptions of caring for families. Journal of Clinical Nursing, 9(4), 611–619. Katz, J., Sedell, M., & Komaromy, C. (2000). Death in homes: Bereavement needs of residents, relatives, and staff. International Journal of Palliative Nursing, 6(6), 274–279. Levy, L. H. (1991). Anticipatory grief: Its measurement and proposed reconceptualization. Hospice Journal, 7(4), 1–28. Nishimoto, P. (1996). Venturing into the unknown: Cultural beliefs about death and dying. Oncology Nursing Forum, 23(6), 889–894. Posttraumatic Stress Disorder Ellensweig-Tepper, D. (2000). Trauma group therapy for the adolescent female client. Journal of Child and Adolescent Psychiatric Nursing, 13(1), 17–28. McGrath, P. (1999). Posttraumatic stress and the experience of cancer: A literature review. Journal of Rehabilitation, 65(3), 17–23. Miller, J. L. (2000). Post-traumatic stress disorder in primary care. Journal of the American Academy of Nurse Practitioners, 12(11), 475–485. Spirituality Byrd, E. K. (1999). Spiritual care matters: Application of helping theories and faith in the lives of persons with disabilities. Journal of Religion, Disability, and Health, 3(1), 3–13. Chandler, E. (1999). Spirituality. Hospice Journal, 14(3/40), 63–74. Dunn, K. S., & Horgas, A. L. (2000). The prevalence of prayer as a spiritual self-care modality in elders. Journal of Holistic Nursing, 18(4), 337–351. Dyson, J., Cobb, M. & Forman, D. (1997). The meaning of spirituality: A literature review. Journal of Advanced Nursing, 26(6), 1183–1188. Haln, M. A., Myers, R. N., & Bennetts, P. (2000). Providing spiritual care to cardiac patients: Assessment and implications for practice. Critical Care Nurse, 20(4), 54–56, 58, 64, 66–72. Havranek, J. E. (1999). The role of spirituality in the rehabilitation process. Journal of Religion, Disability, and Health, 3(2), 15–35. *Humphreys, J. (2000). Spirituality and distress in sheltered battered women. Scholarly Inquiry for Nursing Practice, 14(2), 115–141. Kendrick, K. D., & Robinson, S. (2000). Spirituality: Its relevance and purpose for clinical nursing in a new millennium. Journal of Clinical Nursing, 9(5), 701–705. Langer, N. (2000). The importance of spirituality in later life. Gerontology and Geriatric Education, 20(3), 41–50. Sheldon, T. E. (2000). Spirituality as a part of nursing. Journal of Hospice and Palliative Care, 2(3), 101–108. Sherwood, G. D. (2000). The power of nurse-client encounters interpreting spiritual themes. Journal of Holistic Nursing, 18(2), 159–175.
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Sumner, C. H. (1998). Recognizing and responding to spiritual distress. American Journal of Nursing, 98(1), 26–30. Sussman, D. (2000). A spiritual approach: Nurses and chaplains team up to provide pastoral care. Healthweek, 5(17), 12. Sussman, S., Nezami, E., & Mishra, S. (1997). On operationalizing spiritual experience for health promotion research and practice. Alternative Therapies in Clinical Practice, 4(4), 120–125. Treloar, L. L. (2000). Integration of spirituality into health care practice by nurse practitioners. Journal of American Academy of Nurse Practitioners, 12(7), 280–285. Substance Abuse Ewing, J. A. (1984). Detecting alcoholism: The CAGE questionnaire. Journal of American Medical Association, 252(14), 1906. McLellan, A. T., Kushner, H., Metzger, D., & Peters, R. (1992). The fifth edition of the addiction severity index. Journal of Substance Abuse Treatment, 9(3), 199–213. Sedlak, C. A., Dokery, M. O., Estok, P. J., & Zeller, R. A. (2000). Alcohol use in women 65 years of age and older. Health Care of Women International, 21(7), 567–581. Selzer, M. L. (1971). The Michigan alcoholism screening test: The quest for a new diagnostic instrument. American Journal of Psychiatry, 127, 1653–1658. Sturn, R., & Sherbourne, C. D. (2000). Data points: Managed care and unmet need for mental health and substance abuse care in 1998. Psychiatric Services, 51(2), 177.
RESOURCES AND WEBSITES Agencies American Holistic Nurses Association (AHNA), P.O. Box 2130, Flagstaff, AZ 86003-2130; 1-800-278-AHNA; http://www.ahna. org. Grief Recovery Institute Education Foundation, Inc. (GRIEF), P.O. Box 6061-382, Sherman Oaks, CA 91413; 1-818-907-9600; 1-800445-4808 (Hotline); http://www.grief.net. National Hospice Organization (NHO), 1901 North Moore Street, Suite 901, Arlington, VA 22209; 1-703-243-5900. Aging American Association of Retired Persons (AARP), 601 “E” Street NW, Washington, DC 20049-0001; 1-202-434-2277; 1-800-424-3410; http://www.aarp.org. Children of Aging Parents, 1609 Woodbourne Road #302A, Levittown, PA 19057-1511; 1-215-945-6900; 1-800-227-7294. National Association for Families Caring for their Elders—Eldercare America, 1141 Loxford Terrace, Silver Spring, MD 20901-1130; 1-301-593-1621. National Council on the Aging, 409 3rd Street SW, Washington, DC 20024; 1-202-424-1200; 1-800-424-9046;
[email protected]. National Office of the Gray Panthers, P.O. Box 214777, Washington, DC 20009; 1-202-466-3132; 1-800-280-5362;
[email protected]. Anxiety Anxiety Disorders Association of America, 11900 Parklawn Drive #100, Rockville, MD 20852-2624; 1-301-231-9350;
[email protected].
Bereavement Compassionate Friends, P.O. Box 3696, Oak Brook, IL 60522-3696; 1-630-990-0010; nationaloffi
[email protected]; http:// www.compassionatefriends.org. They Help Each Other Spiritually (THEOS), 322 Boulevard of the Allies #105, Pittsburgh, PA 15222-1919; 1-412-471-7779. Widowed Persons Service, 601 “E” Street NW, Washington, DC 20049-0001; 1-202-434-2260. Depression Depression Awareness, Recognition, and Treatment (D/ART), NIMH, 5600 Fishers Lane Room 10-85, Rockville, MD 20857; 1-800-4214211; 1-301-443-4140. National Alliance for the Mentally Ill, 200 N. Grebe Road #1015, Arlington, VA 22201-3062; 1-703-524-7600; 1-800-950-NAMI;
[email protected]. National Mental Health Association, 1021 Prince Street, Alexandria, VA 22314-2971; 1-703-684-7722; 1-800-969-6642; 1-800-433-5959;
[email protected]. Eating Disorders American Anorexia Bulimia Association Inc., 165 W. 46th Street, #1108, New York, NY 10036-2501; 1-212-575-6200. National Eating Disorders Association (NEDO), 6655 S. Yale Avenue, Tulsa, OK 74136; 1-918-481-4044. Posttraumatic Stress Disorder National Center for PTSD, VA Medical Center (116D), White River Junction, VT 05009; 1-802-296-5132;
[email protected]. Substance Abuse Adult Children of Alcoholics, P.O. Box 3216, Torrence, CA 90510; 1-310-534-1815; http://
[email protected]. Alanon and Alateen Family Group Headquarters Inc., 1600 Corporate Landing Parkway, Virginia Beach, VA 23454-5617; 1-888-4ALANON (888-425-2666); http://www.al-anon.org. Alcoholics Anonymous, Grand Central Station, P.O. Box 459, New York, NY 10163; 1-212-870-3400; http://www.alcoholicsanonymous.org. Children of Alcoholics Foundation, 164 West 74th Street, New York, NY 10115; 1-800-359-2623. Co-Anon Family Groups, P.O. Box 64742-66, Los Angeles, CA 90064; 1-818-377-4317. Cocaine Anonymous, 3740 Overland Avenue Suite G, Los Angeles, CA 90034; 1-800-347-8998; http://www.ca.org. Dual Recovery Anonymous World Services, P.O. Box 8107, Prairie Village, KS 66208; 877-883-2332; http://www.DRAonline.org. Narcotics Anonymous, P.O. Box 9999, Van Nuys, CA 91409; 1-818773-9999; http://www.na.org. Rational Recovery Systems, Box 800, Lotus, CA 95651; 1-530-6214374. Secular Organizations for Sobriety (SOS), The Center for Inquiry, 5521 Grosvenor Boulevard, Los Angeles, CA 90066; 1-310-821-8430.
Hotline Numbers Center for Substance Abuse Prevention Workplace, Hotline 800WORKPLACE (1-800-967-5752). Center for Substance Abuse Treatment, National Treatment Hotline 800-662-HELP (1-800-662-4357). National Alcohol Hotline, Helpline: 1-800-NCA-CALL (1-800-6222255). National Cocaine Hotline, 1-800-COCAINE (1-800-2622463).
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Perspectives in Transcultural Nursing
LEARNING OBJECTIVES
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On completion of this chapter, the learner will be able to: 1. Apply transcultural nursing principles, concepts, and theories when 2. 3. 4.
providing nursing care to patients (individuals, families, groups, and communities). Develop strategies for planning, providing, and evaluating culturally competent nursing care for patients from diverse backgrounds. Critically analyze the influence of culture on nursing care decisions and actions for patients. Identify key components of cultural assessment for self and patients.
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n the health care delivery system, as in society, the nurse interacts with people of similar and diverse cultural backgrounds. People may have similar or different frames of reference and varied preferences regarding their health and health care needs. Acknowledging and adapting to the cultural needs of the patient and significant others is an important component of nursing care. To plan and deliver culturally competent care, the nurse must understand the definitions of culture and cultural competence and the various aspects of culture that should be explored for each patient.
Definitions of Culture The concept of culture and its relationship to the health care beliefs and practices of patients and their families and friends provide the foundation for transcultural nursing. This awareness of culture in the delivery of nursing care has been described in different ways, including respect for cultural diversity, culturally sensitive or comprehensive care, and culturally competent or appropriate nursing care (American Association of Colleges of Nursing, 1996; Giger & Davidhizar, 1999; Spector, 2000), or culturally congruent nursing care (Leininger, 2001). Two commonly discussed concepts are cultural diversity and culturally competent care. The term culture was initially defined by the British anthropologist Sir Edward Tylor in 1871 as the knowledge, belief, art, morals, laws, customs, and any other capabilities and habits acquired by humans as members of society. During the past century, and especially during recent decades, hundreds of definitions of culture have been offered that integrate the themes stated by Tylor and the themes of ethnic variations of a population based on race, nationality, religion, language, physical characteristics, and geography (Spector, 2000). To fully appreciate the impact of culture, aspects such as disabilities, gender, social class, physical appearance (eg, weight, height), ideologies (political views), or sexual orientation must be integrated into the definition of culture as well (Gooden, Porter, Gonzalez, & Mims, 2001). Madeleine Leininger, founder of the specialty called transcultural nursing, indicates that culture involves learned and transmitted knowledge about values, beliefs, rules of behavior, and lifestyle practices that guide designated groups in their thinking and actions in patterned ways (2001). Giger and Davidhizar (1999) state that transcultural nursing is a practice based on the differences and similarities between cultures in relation to health, health care, and illness, with consideration of patient values, beliefs, and practices. Further, culture develops over time as a result of “imprinting the mind through social and religious structures and intellectual and artistic manifestations” (p. 3). The concept of ethnic culture has four basic characteristics:
• It is learned from birth through language and socialization. • It is shared by members of the same cultural group, and it • •
includes an internal sense and external perception of distinctiveness. It is influenced by specific conditions related to environmental and technical factors and to the availability of resources. It is dynamic and ever-changing.
With the exception of the first characteristic, culture related to age, physical appearance, lifestyle, and other less frequently acknowledged aspects also adhere to the above characteristics. Cultural diversity has also been defined in a number of ways. Often, skin color, religion, and geographic area are the only elements used to identify diversity, with ethnic minorities being considered the primary sources of cultural diversity. As stated ear-
lier, however, there are several other possible sources of cultural diversity. In addition, to truly acknowledge the cultural differences that may influence health care delivery, the nurse must recognize the influence of his or her own culture and cultural heritage (Krumberger, 2000). Culturally competent nursing care has been defined as effective, individualized care that considers cultural values, is culturally aware and sensitive, and incorporates cultural skills (Hunt, 2000; Krumberger, 2000; Wilkinson, 2001). Culturally competent care is a dynamic process that requires comprehensive knowledge of culture-specific information and an awareness of, and sensitivity to, the effect that culture has on the care situation. It requires the nurse to integrate cultural knowledge, awareness of his or her own cultural perspective, and the patient’s cultural perspectives into the plan of care (Giger & Davidhizar, 1999). Exploring one’s own cultural beliefs and how they might conflict with the beliefs of the patients being cared for is a first step toward becoming culturally competent (Krumberger, 2000). Understanding the diversity within cultures, such as subcultures, is also important.
SUBCULTURES AND MINORITIES Although culture is a universal phenomenon, it takes on specific and distinctive features for a particular group, since it encompasses all of the knowledge, beliefs, customs, and skills acquired by the members of that group. When such groups function within a larger cultural group, they are referred to as subcultures. The term subculture is used for relatively large groups of people who share characteristics that enable them to be identified as a distinct entity. Examples of American subcultures based on ethnicity (ie, subcultures with common traits such as physical characteristics, language, or ancestry) include African Americans, Hispanic/Latino Americans, and Native Americans. Each of these subcultures may be further divided; for example, Native Americans consist of American Indians and Alaska Natives, who represent more than 500 federally and state-recognized tribes in addition to an unknown number of tribes that receive no official recognition. Subcultures may also be based on religion (more than 1200 exist in the United States), occupation (eg, nurses, physicians, other members of the health care team), or shared disability or illness (eg, the Deaf community). In addition, subcultures may be based on age (eg, infants, children, adolescents, adults, older adults), gender (eg, male, female); sexual orientation (eg, homosexual or bisexual men and women), or geographic location (eg, Texans, Southerners, Appalachians). The nurse should also be sensitive to the intraracial applications of cultural competence. Tensions between subcultures within a designated group could add to the complexity of planning culturally competent care. Some members of one ethnic subculture may be offended or angered if mistaken for members of a different subculture. Similarly, if the attributes of one subculture are mistakenly generalized to a patient belonging to a different subculture, extreme offense could result, as well as inappropriate care planning and implementation (Fields, 2000). It is crucial that nurses refrain from culturally stereotyping a patient in an attempt to be culturally competent. Instead, the patient or significant others should be consulted regarding personal values, beliefs, preferences and cultural identification. This strategy is also applicable for members of nonethnic subcultures. The term minority refers to a group of people whose physical or cultural characteristics differ from the majority of people in a society. At times, minorities may be singled out or isolated from others in society or treated in different or unequal ways. Although
Chapter 8 there are four federally identified minority groups—Blacks/African Americans, Hispanics, Asian/Pacific Islanders, and Native Americans (Andrews & Boyle, 1999)—the concept of “minority” varies widely and must be understood in a cultural context. For example, men may be considered a minority within the nursing profession, but they constitute a majority within the field of medicine. In addition, Caucasians may be in the minority in some communities in the United States, but they are currently the majority group in the country (although it has been projected that by the middle to late 21st century, Caucasians will be in the minority in the United States). Because at times the term minority connotes inferiority, members of many racial and ethnic groups object to being identified as minorities.
Transcultural Nursing Transcultural nursing, a term sometimes used interchangeably with cross-cultural, intercultural, or multicultural nursing, refers to a formal area of study and practice that focuses on the cultural care (caring) values, beliefs, and practices of individuals and groups from a particular culture (Giger & Davidhizar, 1999). The underlying focus of transcultural nursing is to provide culture-specific and culture-universal care that promotes the wellbeing or health of individuals, families, groups, communities, and institutions (Giger & Davidhizar, 1999; Leininger, 2001). When culturally appropriate care is provided, all individuals, and the community or institution at large, benefit. When the care is delivered beyond the nurse’s national boundaries, the term international or transnational nursing is often used. Although many nurses, anthropologists, and others have written about the cultural aspects of nursing and health care, Leininger (2001) developed a comprehensive research-based theory called Culture Care Diversity and Universality. The goal of the theory is to provide culturally congruent nursing care to improve care for people of different or similar cultures. This means promoting recovery from illness, preventing conditions that would limit the patient’s health or well-being, or facilitating a peaceful death in ways that are culturally meaningful and appropriate. Nursing care needs to be tailored to fit the patient’s cultural values, beliefs, and lifestyle. Leininger’s theory includes providing culturally congruent nursing care (meaningful, beneficial, and satisfying health care tailored to fit the patient’s cultural values) through culture care accommodation and culture care restructuring (Fig. 8-1). Culture care accommodation refers to those professional actions and decisions that a nurse makes in his or her care to help people of a designated culture achieve a beneficial or satisfying health outcome. Culture care restructuring or repatterning refers to those professional actions and decisions that help patients reorder, change, or modify their lifestyles toward new, different, or more beneficial health care patterns. At the same time, the patient’s cultural values and beliefs are respected, and a better or healthier lifestyle is provided. Other terms and definitions that provide further insight into culture and health care include the following:
• Acculturation is the process by which members of a cultural •
group adapt to or learn how to take on the behaviors of another group. Cultural blindness is the inability of a person to recognize his or her own values, beliefs, and practices and those of others because of strong ethnocentric tendencies (the tendency to view one’s own culture as superior to others).
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• Cultural imposition is the tendency to impose one’s cultural •
beliefs, values, and patterns of behavior on a person or persons from a different culture. Cultural taboos are those activities governed by rules of behavior that are avoided, forbidden, or prohibited by a particular cultural group.
Culturally Competent Nursing Care Culturally competent or congruent nursing care refers to the complex integration of attitudes, knowledge, and skills (including assessment, decision making, judgments, critical thinking, and evaluation) that enables the nurse to provide care in a culturally sensitive and appropriate manner. Agency and institutional policies are important to achieve culturally competent care. Policies that promote culturally competent care establish flexible regulations pertaining to visitors (number, frequency, and length of visits), provide translation services for non–Englishspeaking patients, and train staff to provide care for patients with different cultural values (Suro, 2000). Culturally competent policies also recognize the special dietary needs of patients from selected cultural groups and create an environment in which the traditional healing, spiritual, and religious practices of patients are respected and encouraged. Giger and Davidhizar (1999) created an assessment model to guide the nurse in exploring cultural phenomena that might affect nursing care. They identified communication, space, time orientation, social organization, environmental control, and biologic variations as relevant phenomena (Giger & Davidhizar, 1999). This model has been used in various patient care settings to provide data essential to the provision of culturally competent care.
CROSS-CULTURAL COMMUNICATION Establishing an environment of culturally congruent care and respect begins with effective communication, which occurs not only through words, but also through body language and other cues, such as voice, tone, and loudness. Nurse–patient interactions, as well as communications among members of a multicultural health care team, are dependent on the ability to understand and be understood. Approximately 150 different languages are spoken in the United States, with Spanish accounting for the largest percentage after English. Obviously, nurses cannot become fluent in all languages, but certain strategies for fostering effective cross-cultural communication are necessary when providing care for patients who are not fluent in English. Cultural needs should be considered when choosing an interpreter; fluency in varied dialects, for instance, is beneficial (Suro, 2000). The interpreter’s voice quality, pronunciation, use of silence, use of touch, and use of nonverbal communication should also be assessed (Giger & Davidhizar, 1999). During illness, patients of all ages tend to regress, and the regression often involves language skills. Chart 8-1 summarizes suggested strategies for overcoming language barriers. The nurse should also assess how well the patient and family have understood what has been said. The following cues may signal lack of effective communication:
• Efforts to change the subject. This could indicate that the
patient does not understand what you are saying and is attempting to talk about something more familiar.
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FIGURE 8-1 Leininger’s Sunrise Model depicts theory of cultural care diversity and universality. From Leininger, M. M. (Ed.). (2001). Culture care diversity and university: A theory of nursing. New York: New York: National League for Nursing Press. • Absence of questions. Paradoxically, this often means that • •
the listener is not grasping the message and therefore has difficulty formulating questions to ask. Inappropriate laughter. A self-conscious giggle may signal poor comprehension and may be an attempt to disguise embarrassment. Nonverbal cues. Although a blank expression may signal poor understanding, among some Asian Americans it may reflect a desire to avoid overt expression of emotion. Similarly, avoidance of eye contact may be a cultural expression of respect for the speaker; some Native Americans and Asian Americans use this gesture.
Culturally Mediated Characteristics Nurses should be aware that patients act and behave in a variety of ways, in part because of the influence of culture on behaviors and attitudes. However, although certain attributes and attitudes are frequently associated with particular cultural groups, as described in the following pages, it is important to remember that
not all people from the same cultural background share the same behaviors and views. Although the nurse who fails to consider a patient’s cultural preferences and beliefs is considered insensitive and possibly indifferent, the nurse who assumes that all members of any one culture act and behave in the same way runs the risk of stereotyping people. The best way to avoid stereotyping is to view each patient as an individual and to find out the patient’s cultural preferences. A thorough culture assessment using a culture assessment tool or questionnaire (see later discussion) is very beneficial.
SPACE AND DISTANCE People tend to regard the space in their immediate vicinity as an extension of themselves. The amount of space they need between themselves and others to feel comfortable is a culturally determined phenomenon. Because nurses and patients usually are not consciously aware of their personal space requirements, they frequently have difficulty understanding different behaviors in this regard. For exam-
Chapter 8
Chart 8-1
Overcoming Language Barriers
• Greet the patient using the last or complete name. Avoid being • •
• • • • • • •
• • • •
•
too casual or familiar. Point to yourself and say your name. Smile. Proceed in an unhurried manner. Pay attention to any effort by the patient or family to communicate. Speak in a low, moderate voice. Avoid talking loudly. Remember that there is a tendency to raise the volume and pitch of your voice when the listener appears not to understand. The listener may perceive that you are shouting and/or angry. Organize your thoughts. Repeat and summarize frequently. Use audiovisual aids when feasible. Use short, simple sentence structure and speak in the active voice. Use simple words, such as “pain” rather than “discomfort.” Avoid medical jargon, idioms, and slang. Avoid using contractions, such as don’t, can’t, won’t. Use nouns repeatedly instead of pronouns. Example: Do not say: “He has been taking his medicine, hasn’t he?” Do say: “Does Juan take medicine?” Pantomime words (use gestures) and simple actions while verbalizing them. Give instructions in the proper sequence. Example: Do not say: “Before you rinse the bottle, sterilize it.” Do say: “First, wash the bottle. Second, rinse the bottle.” Discuss one topic at a time, and avoid giving too much information in a single conversation. Avoid using conjunctions. Example: Do not say: “Are you cold and in pain?” Do say (while pantomiming/gesturing): “Are you cold?” “Are you in pain?” Validate whether the person understands by having him or her repeat instructions, demonstrate the procedure, or act out the meaning. Use any words you know in the person’s language. This indicates that you are aware of and respect the patient’s primary means of communicating. Try a third language. Many Indo-Chinese speak French. Europeans often know three or four languages. Try Latin words or phrases, if you are familiar with the language. Ask who among the patient’s family and friends could serve as an interpreter. Be aware of culturally based gender and age differences and diverse socioeconomic, educational, and tribal/regional differences when choosing an interpreter. Obtain phrase books from a library or bookstore, make or purchase flash cards, contact hospitals for a list of interpreters, and use both formal and informal networking to locate a suitable interpreter. Although they are costly, some telecommunication companies provide translation services.
ple, one patient may perceive the nurse sitting close to him or her as an expression of warmth and care; another patient may perceive the nurse’s act as a threatening invasion of personal space. Research reveals that people from the United States, Canada, and Great Britain require the most personal space between themselves and others, whereas those from Latin America, Japan, and the Middle East need the least amount of space and feel comfortable standing close to others. If patients appear to position themselves too close or too far away, the nurse should consider cultural preferences for space and distance. Ideally, patients should be permitted to assume a position that is comfortable to them in terms of personal space and distance. Because a significant amount of communication during nursing care requires close physical contact, the nurse should be aware of these important cultural differences and consider them when delivering care (Davidhizar, Dowd, & Newman-Giger, 1999).
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EYE CONTACT Eye contact is also a culturally determined behavior. Although most nurses have been taught to maintain eye contact when speaking with patients, some people from certain cultural backgrounds may interpret this behavior differently. Some Asians, Native Americans, Indo-Chinese, Arabs, and Appalachians, for example, may consider direct eye contact impolite or aggressive, and they may avert their own eyes when talking with nurses and others whom they perceive to be in positions of authority. Some Native Americans stare at the floor during conversations, a cultural behavior conveying respect and indicating that the listener is paying close attention to the speaker. Some Hispanic patients maintain downcast eyes as a sign of appropriate deferential behavior toward others on the basis of age, gender, social position, economic status, and position of authority. Being aware that whether a person makes eye contact may be a result of the culture from which they come will help the nurse understand a patient’s behavior and provide an atmosphere in which the patient can feel comfortable.
TIME Attitudes about time vary widely among cultures and can be a barrier to effective communication between nurses and patients. Views about punctuality and the use of time are culturally determined, as is the concept of waiting. Symbols of time, such as watches, sunrises, and sunsets, represent methods for measuring the duration and passage of time (Giger & Davidhizar, 1999; Spector, 2000). For most health care providers, time and promptness are extremely important. For example, nurses frequently expect patients to arrive at an exact time for an appointment, despite the fact that the patient is often kept waiting by health care providers who are running late. Health care providers are likely to function according to an appointment system in which there are short intervals of perhaps only a few minutes. For patients from some cultures, however, time is a relative phenomenon, with little attention paid to the exact hour or minute. Some Hispanic people, for example, consider time in a wider frame of reference and make the primary distinction between day and night. Time may also be determined according to traditional times for meals, sleep, and other activities or events. For people from some cultures, the present is of the greatest importance, and time is viewed in broad ranges rather than in terms of a fixed hour. Being flexible in regard to schedules is the best way to accommodate these differences. Value differences also may influence a person’s sense of priority when it comes to time. For example, responding to a family matter may be more important to a patient than meeting a scheduled health care appointment. Allowing for these different views is essential in maintaining an effective nurse-patient relationship. Scolding or acting annoyed at a patient for being late undermines the patient’s confidence in the health care system and might result in further missed appointments or indifference to health care suggestions.
TOUCH The meaning people associate with touching is culturally determined to a great degree. In some cultures (eg, Hispanic, Arab), male health care providers may be prohibited from touching or examining certain parts of the female body. Similarly, it may be inappropriate for females to care for males. Among many Asian Americans, it is impolite to touch a person’s head because the
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spirit is believed to reside there. Therefore, assessment of the head or evaluation of a head injury requires alternative approaches. The patient’s culturally defined sense of modesty must also be considered when providing nursing care. For example, some Jewish and Islamic women believe that modesty requires covering their head, arms, and legs with clothing.
COMMUNICATION Many aspects of care may be influenced by the diverse cultural perspectives held by the health care providers, patient, family, or significant others. One example is the issue of informed consent and full disclosure. In general, a nurse may argue that patients have the right to full disclosure about their disease and prognosis and may feel that advocacy means working to provide that disclosure. Family members of some cultural backgrounds may believe it is their responsibility to protect and spare the patient, their loved one, the knowledge of a terminal illness. Similarly, patients may, in fact, not want to know about their condition and may expect their family members to “take the burden” of that knowledge and related decision-making (Kudzma, 1999). The nurse should not decide that the family or patient is simply wrong or that the patient must know all details of his or her illness. Similar concerns may be noted when patients refuse pain medication or treatment because of cultural beliefs regarding pain or belief in divine intervention or faith healing. Determining the most appropriate and ethical approach to patient care requires an exploration of the cultural aspects of these situations. Self-examination by the nurse and recognition of one’s own cultural bias and world view, as discussed earlier, will play a major part in helping the nurse to resolve cultural and ethical conflicts. The nurse must promote open dialogue and work with the patient, family, physician, and other health care providers to reach the culturally appropriate solution for the patient.
OBSERVANCE OF HOLIDAYS People from all cultures celebrate civil and religious holidays. Nurses should familiarize themselves with major holidays for members of the cultural groups they serve. Information about these important celebrations is available from various sources, including religious organizations, hospital chaplains, and patients themselves. Routine health appointments, diagnostic tests, surgery, and other major procedures should be scheduled to avoid those holidays a patient identifies as significant. Efforts should also be made to accommodate patients and family or significant others, when not contraindicated, as they perform holiday rituals in the health care setting.
DIET The cultural meanings associated with food vary widely but usually include one or more of the following: relief of hunger; promotion of health and healing; prevention of disease or illness; expression of caring for another; promotion of interpersonal closeness among individuals, families, groups, communities, or nations; and promotion of kinship and family alliances. Food may also be associated with solidification of social ties; celebration of life events (eg, birthdays, marriages, funerals); expression of gratitude or appreciation; recognition of achievement or accomplishment; validation of social, cultural, or religious ceremonial functions; facilitation of business negotiations; and expression of affluence, wealth, or social status.
Culture determines which foods are served and when they are served, the number and frequency of meals, who eats with whom, and who is given the choicest portions. Culture also determines how foods are prepared and served; how they are eaten (with chopsticks, hands, or fork, knife, and spoon); and where people shop for their favorite food items (eg, ethnic grocery stores, specialty food markets). Religious practices may include fasting (eg, Mormons, Catholics, Buddhists, Jews, Muslims), abstaining from selected foods at particular times (eg, Catholics abstain from meat on Ash Wednesday and on Fridays during Lent), and considerations for medications (eg, Muslims may prefer to use non-pork-derived insulin). Practices may also include the ritualistic use of food and beverages (eg, Passover dinner, consumption of bread and wine during religious ceremonies). Chart 8-2 summarizes some dietary practices of selected religious groups. Many groups tend to feast, often in the company of family and friends, on selected holidays. For example, many Christians eat large dinners on Christmas and Easter and consume other traditional high-calorie, high-fat foods, such as seasonal cookies, pastries, and candies. These culturally-based dietary practices are especially significant in the care of patients with diabetes, hypertension, gastrointestinal disorders, and other conditions in which diet plays a key role in the treatment and health maintenance regimen.
Chart 8-2
Prohibited Foods and Beverages of Selected Religious Groups
Hinduism All meats Animal shortenings Islam Pork Alcoholic products and beverages (including extracts, such as vanilla and lemon) Animal shortenings Gelatin made with pork, marshmallow, and other confections made with gelatin Judaism Pork Predatory fowl Shellfish and scavenger fish (eg, shrimp, crab, lobster, escargot, catfish). Fish with fins and scales are permissible. Mixing milk and meat dishes at same meal Blood by ingestion (eg, blood sausage, raw meat). Blood by transfusion is acceptable. Note: Packaged foods will contain labels identifying kosher (“properly preserved” or “fitting”) and pareve (made without meat or milk) items. Mormonism (Church of Jesus Christ of Latter-Day Saints) Alcohol Tobacco Beverages containing caffeine stimulants (coffee, tea, colas, and selected carbonated soft drinks) Seventh-Day Adventism Pork Certain seafood, including shellfish Fermented beverages Note: Optional vegetarianism is encouraged.
Chapter 8 BIOLOGIC VARIATIONS Along with psychosocial adaptations, nurses must also consider the physiologic impact of culture on patient response to treatment, particularly medications. Data have been collected for many years regarding differences in the effect some medications have on persons of diverse ethnic or cultural origins. Genetic predispositions to different rates of metabolism cause some patients to be prone to overdose reactions to the “normal dose” of a medication, while other patients are likely to experience a greatly reduced benefit from the standard dose of the medication. An antihypertensive agent, for example, may work well for a white male client within a 4-week time span but may take much longer to work or not work at all for an African-American male patient with hypertension. General polymorphism—variation in response to medications resulting from patient age, gender, size, and body composition—has long been acknowledged by the health care community (Kudzma, 1999). Culturally competent medication administration requires that consideration of ethnicity and related factors such as values and beliefs regarding the use of herbal supplements, dietary intake, and genetic factors can affect the effectiveness of treatment and compliance with the treatment regimen (Giger & Davidhizar, 1999; Kudzma, 1999).
COMPLEMENTARY AND ALTERNATIVE THERAPIES Interventions for alterations in health and wellness vary among cultures. Interventions most commonly used in the United States have been labeled as conventional medicine by the National Institutes of Health (n.d.). Other names for conventional medicine were allopathy, Western medicine, regular medicine, mainstream medicine, and biomedicine. Interest in interventions that are not an integral part of conventional medicine prompted the National Institutes of Health to create the Office of Alternative Medicine (OAM) in 1992, and then to establish the National Center for Complementary and Alternative Medicine (NCCAM) in 1999. The NCCAM grouped complementary and alternative medicine interventions into five main categories: alternative medical systems, mind–body interventions, biologically based therapies, manipulative and body-based methods, and energy therapies (National Institutes for Health, National Center for Complementary and Alternative Medicine, accessed 9/8/01).
• Alternative medical systems are defined as complete systems
•
•
of theory and practice that are different from conventional medicine. Some examples are traditional Eastern medicine (including acupuncture, herbal medicine, oriental massage, and Qi gong); India’s traditional medicine, Ayurveda (including diet, exercise, meditation, herbal medicine, massage, exposure to sunlight, and controlled breathing to restore harmony of an individual’s body, mind, and spirit); homeopathic medicine (including herbal medicine and minerals); and naturopathic medicine (including diet, acupuncture, herbal medicine, hydrotherapy, spinal and soft-tissue manipulation, electrical currents, ultrasound and light therapy, therapeutic counseling, and pharmacology). Mind–body interventions are defined as techniques to facilitate the mind’s ability to affect symptoms and bodily functions. Some examples are meditation, dance, music, art therapy, prayer, and mental healing. Biologically based therapies are defined as natural and biologically based practices, interventions, and products. Some examples are herbal therapies (an herb is a plant or plant
•
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part that produces and contains chemical substances that act upon the body), special diet therapies (such as those of Drs. Atkins, Ornish, and Pritikin), orthomolecular therapies (magnesium, melatonin, megadoses of vitamins), and biologic therapies (shark cartilage, bee pollen). Manipulative and body-based methods are defined as interventions based on body movement. Some examples are chiropracty (primarily manipulation of the spine), osteopathic manipulation, massage therapy (soft tissue manipulation), and reflexology. Energy therapies are defined as interventions that focus on energy fields within the body (biofields) or externally (electromagnetic fields). Some examples are Qi gong, Reiki, therapeutic touch, pulsed electromagnetic fields, magnetic fields, alternating electrical current, and direct electrical current.
A patient may choose to seek an alternative to conventional medical or surgical therapies. Many of these alternative therapies are becoming widely accepted as feasible treatment options. Therapies such as acupuncture and herbal treatments may be recommended by a patient’s physician to address aspects of a condition that are unresponsive to conventional medical treatment or to minimize side effects associated with conventional medical therapy. Alternative therapy used to supplement conventional medicine may be referred to as complementary therapy. Physicians and advanced practice nurses may work in collaboration with an herbalist or with a spiritualist or shaman to provide a comprehensive treatment plan for the patient. Out of respect for the way of life and beliefs of patients from different cultures, it is often necessary that the healers and health care providers respect the strengths of each approach (Palmer, 2001). Complementary therapy is becoming more common as health care consumers become more aware of what is available through information in printed media and on the Internet. As patients become more informed, they are more likely to participate in a variety of therapies in conjunction with their conventional medical treatments. The nurse needs to assess each patient for use of complementary therapies, remain alert to the danger of conflicting treatments, and be prepared to provide information to the patient regarding treatment that may be harmful. The nurse must, however, be accepting of the patient’s beliefs and right to control his or her own care. As a patient advocate, the nurse facilitates the integration of conventional medical, complementary, and alternative medical therapies.
Causes of Illness Three major views, or paradigms, attempt to explain the causes of disease and illness: the biomedical or scientific view, the naturalistic or holistic perspective, and the magico-religious view.
BIOMEDICAL OR SCIENTIFIC The biomedical or scientific world view prevails in most health care settings and is embraced by most nurses and other health care providers. The basic assumptions underlying the biomedical perspective are that all events in life have a cause and effect, that the human body functions much like a machine, and that all of reality can be observed and measured (eg, blood pressures, PaO2 levels, intelligence tests). One example of the biomedical or scientific view is the bacterial or viral explanation of communicable diseases.
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NATURALISTIC OR HOLISTIC The second way that some cultures explain the cause of illness is through the naturalistic or holistic perspective, a viewpoint that is found among many Native Americans, Asians, and others. According to this view, the forces of nature must be kept in natural balance or harmony. One example of a naturalistic belief, held by many Asian groups, is the yin/yang theory, in which health is believed to exist when all aspects of a person are in perfect balance or harmony. Rooted in the ancient Chinese philosophy of Taoism (which translates as “The Way”), the yin/yang theory proposes that all organisms and objects in the universe consist of yin and yang energy. The seat of the energy forces is within the autonomic nervous system, where balance between the opposing forces is maintained during health. Yin energy represents the female and negative forces, such as emptiness, darkness, and cold, whereas the yang forces are male and positive, emitting warmth and fullness. Foods are classified as cold (yin) or hot (yang) in this theory and are transformed into yin and yang energy when metabolized by the body. Cold foods are eaten when the person has a hot illness (eg, fever, rash, sore throat, ulcer, infection), and hot foods are eaten with a cold illness (eg, cancer, headache, stomach cramps, colds). The yin/yang theory is the basis for Eastern or Chinese medicine and is embraced by some Asian Americans. Many Hispanic, African American, and Arab groups also embrace the hot/cold theory of health and illness. The four humors of the body—blood, phlegm, black bile, and yellow bile—regulate basic bodily functions and are described in terms of temperature and moisture. The treatment of disease consists of adding or subtracting cold, heat, dryness, or wetness to restore the balance of these humors. Beverages, foods, herbs, medicines, and diseases are classified as hot or cold according to their perceived effects on the body, not their physical characteristics. According to the hot/cold theory, the individual as a whole, not just a particular ailment, is significant. Those who embrace the hot/cold theory maintain that health consists of a positive state of total well-being, including physical, psychological, spiritual, and social aspects of the person. According to the naturalistic world view, breaking the laws of nature creates imbalances, chaos, and disease. People who embrace the naturalistic paradigm use metaphors such as “the healing power of Nature.” From the perspective of the Chinese, for example, illness is seen, not as an intruding agent, but as a part of life’s rhythmic course and an outward sign of disharmony within.
MAGICO-RELIGIOUS The third major way in which people view the world and explain the causes of illness is the magico-religious world view. This view’s basic premise is that the world is an arena in which supernatural forces dominate and that the fate of the world and those in it depends on the action of supernatural forces for good or evil. Examples of magical causes of illness include belief in voodoo or witchcraft among some African Americans and others from Caribbean countries. Faith healing is based on religious beliefs and is most prevalent among selected Christian religions, including Christian Science, while various healing rituals may be found in many other religions, such as Roman Catholicism and Mormonism (Church of Jesus Christ of Latter Day Saints). Of course, it is possible to hold a combination of world views, and many patients offer more than one explanation for the cause of their illness. As a profession, nursing largely embraces the scientific
or biomedical world view, but some aspects of holism have begun to gain popularity, including a wide variety of techniques for managing chronic pain, such as hypnosis, therapeutic touch, and biofeedback. Belief in spiritual power is also held by many nurses who credit supernatural forces with various unexplained phenomena related to patients’ health and illness states. Regardless of the view held and whether the nurse agrees with the patient’s beliefs in this regard, it is important to be aware of how people view their illness and their health and to work within this framework to promote patients’ care and well-being.
Folk Healers Several cultures believe in folk or indigenous healers. The nurse may find some Hispanic patients, for instance, turning to a curandero or curandera, espiritualista (spiritualist), yerbo (herbalist), or sabador (healer who manipulates bones and muscles). Some African American patients may seek assistance from a hougan (voodoo priest or priestess), spiritualist, root doctor (usually a woman who uses magic rituals to treat diseases), or “old lady” (an older woman who has successfully raised a family and who specializes in child care and folk remedies). Native American patients may seek assistance from a shaman or medicine man or woman. Patients of Asian descent may mention that they have visited herbalists, acupuncturists, or bone setters. Several cultures have their own healers, most of whom speak the native tongue of the patient, make house calls, and cost significantly less than healers practicing in the conventional medical health care system. People seeking complementary and alternative therapies have expanded the practices of folk healers beyond their traditional populations, so the nurse needs to ask patients about participation with folk healers regardless of their cultural background. It is best not to disregard a patient’s belief in a folk healer or try to undermine trust in the healer. To do so may alienate and drive the patient away from receiving the care prescribed. A nurse should make an effort to accommodate the patient’s beliefs while also advocating the treatment proposed by health science.
Cultural Assessment Cultural nursing assessment refers to a systematic appraisal or examination of individuals, families, groups, and communities in terms of their cultural beliefs, values, and practices. The purpose of such an assessment is to provide culturally competent care (Giger & Davidhizar, 1999). In an effort to establish a database for determining a patient’s cultural background, nurses have developed cultural assessment tools or modified existing assessment tools (Spector, 2000; Leininger, 2001) to ensure that transcultural considerations are included in the plan of care. Giger and Davidhizar’s (1999) model has been used to design nursing care from health promotion to nursing skills activities (Giger & Davidhizar, 1999; Smith-Temple & Johnson, 2002). The information presented in this chapter and the following general guidelines can be used to direct the nurse’s assessment of culture and its influence on a patient’s health beliefs and practices.
• What is the patient’s country of origin? How long has the •
patient lived in this country? What is the primary language and literacy level? What is the patient’s ethnic background? Does he or she identify strongly with others from the same cultural background?
Chapter 8 • What is the patient’s religion, and how important is it to his • • • • • • • • • •
or her daily life? Does the patient participate in cultural activities such as dressing in traditional clothing and observing traditional holidays and festivals? Are there any food preferences or restrictions? What are the patient’s communication styles? Is eye contact avoided? How much physical distance is maintained? Is the patient open and verbal about symptoms? Who is the head of the family, and is he or she involved in decision making about the patient? What does the patient do to maintain his or her health? What does the patient think caused the current problem? Has the advice of traditional healers been sought? Have complementary therapies been utilized? What kind of treatment does the patient think will help? What are the most important results he or she hopes to get from this treatment? Are there religious rituals related to health, sickness, or death that the patient observes?
Additional Cultural Considerations: Know Thyself Because the nurse–patient interaction is the focal point of nursing, nurses should consider their own cultural orientation when conducting assessment of the patient and the patient’s family and friends.
• Know your own cultural attitudes, values, beliefs, and • • • • • •
•
•
practices. Regardless of “good intention,” everyone has cultural “baggage” that ultimately results in ethnocentrism. In general, it is easier to understand those whose cultural heritage is similar to our own, while viewing those who are unlike us as strange and different. Maintain a broad, open attitude. Expect the unexpected. Enjoy surprises. Avoid seeing all people as alike; that is, avoid cultural stereotypes, such as “all Chinese like rice” or “all Italians eat spaghetti.” Try to understand the reasons for any behavior by discussing commonalities and differences. If a patient has said or done something that you do not understand, ask for clarification. Be a good listener. Most patients will respond positively to questions that arise from a genuine concern for and interest in them. If at all possible, speak the patient’s language (even simple greetings and social courtesies will be appreciated). Avoid feigning an accent or using words that are ordinarily not part of your vocabulary. Be yourself. There are no right or wrong ways to learn about cultural diversity.
The Future of Transcultural Nursing Care By the middle of the 21st century, the average American patient will trace his or her ancestry to Africa, Asia, the Pacific Islands, or the Hispanic or Arab worlds, rather than to Europe (Giger & Davidhizar, 1999). As indicated previously, the concept of culturally competent care applies to health care institutions, which must develop culturally sensitive policies and provide an atmosphere that fosters the provision of culturally competent care by
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nurses. Those nurses, who reflect the multicultural complexion of our society, must learn to acknowledge and adapt to diversity among their colleagues in the workplace (Davidhizar, Dowd, & Newman-Giger, 1999). In addition, educational institutions must prepare nurses to deliver culturally competent care. Nursing programs, therefore, are exploring creative ways to promote cultural competence in nursing students, including offering multicultural health studies in their curricula (Spector, 2000). An additional issue related to the provision of culturally competent care is the diversity of the health care delivery workforce. Today more than 80% of all nurses are white women. As the population becomes more culturally diverse, efforts to increase the number of ethnic minority nurses must continue and accelerate. Progress in increasing the percentage of culturally diverse nurses has been significantly slower than the increasing percentage of ethnic minority persons in the United States (Buerhaus & Auerbach, 1999). Efforts must be made to facilitate the recruitment and successful program completion of ethnic minority nursing students. With increasing frequency, nurses will be expected to provide culturally competent care for patients. Nurses must work effectively with patients, one another, and other health care team members whose ancestry reflects the multicultural complexion of contemporary society in increasing numbers. Cultural diversity remains one of the foremost issues in health care today.
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Critical Thinking Exercises
1.
You are assigned to care for a hospitalized young male adult whose cultural background is very different from yours. Describe how you would assess his cultural beliefs and practices in developing a plan of nursing care. Explain why it is important to examine your own feelings about his cultural beliefs and practices.
2.
An elderly Hispanic female patient who does not speak English is hospitalized after elective surgery. Even though she is progressing well and her discharge has been planned, her family insists on staying with her for as many hours as possible, refusing to leave when visiting hours are over. How can you help the nursing staff to explore the meaning of the family’s behavior and to understand their own feelings about this behavior? Devise a strategy that you think will help resolve this situation.
3.
You are preparing to discharge an elderly patient who is of foreign origin. The record indicates that she does not speak English and lives alone in a neighborhood where most of the residents are from the same ethnic background as herself. Describe how you would plan discharge teaching to ensure that you can communicate with the patient and family to promote the necessary follow-up care. Explore other aspects of the patient’s and family’s background that you would want to assess to determine the need for referral to a home health care agency.
REFERENCES AND SELECTED READINGS Books American Academy of Nursing, Subpanel on Cultural Competence in Nursing. (1995). Promoting cultural competence in and through nursing education. New York: Author.
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American Association of Colleges of Nursing. (1996). Diversity Task Force Report, October 1996. Washington, D.C.: Author. Andrews, M. M., & Boyle, J. S. (1999). Transcultural concepts in nursing care (3rd ed.). Philadelphia: J. B. Lippincott. Giger, J. N., & Davidhizar, R. E. (1999). Transcultural nursing: Assessment and intervention (3rd ed.). St. Louis: C. V. Mosby. Hunt, R. (2000). Readings in community-based nursing. Philadelphia: Lippincott Williams & Wilkins. Kuhn, M. A. (1999). Complementary therapies for health care providers. Philadelphia: Lippincott Williams & Wilkins. Leininger, M. M. (Ed.). (2001). Culture care diversity and universality: A theory of nursing. New York: National League for Nursing Press. Smith-Temple, J., & Johnson, J. Y. (2002). Nurse’s guide to clinical procedures. (4th ed.). Philadelphia: Lippincott Williams & Wilkins. Spector, R. E. (2000). Cultural diversity in health and illness. New Jersey: Prentice-Hall. Wilkinson, J. M. (2001). Nursing process and critical thinking. New Jersey: Prentice-Hall.
Journals Buerhaus, P. I., & Auerbach, D. (1999). Slow growth in the United States of the number of minorities in the RN workforce. Image: Journal of Nursing Scholarship, 31(2), 179–183. Davidhizar, R., Dowd, S., & Newman-Giger, J. (1999). Managing diversity in the health care workplace. Health Care Supervisor, 17(3), 51–62. Fields, C. D. (2000). Choosing cultural competence over diaspora division. Black Issues in Higher Education, 17(16), 6. Gonzalez, R. I., Gooden, M. B., & Porter, C. P. (2000). Eliminating racial and ethnic disparities in health care. American Journal of Nursing, 100(3), 56–58. Gonzalez, R. (1999). Washington Watch: ANA advocates more diversity in nursing. American Journal of Nursing, 99(11), 24. Gooden, M. B., Porter, C. P., Gonzalez, R. I., & Mims, B. L. (2001). Rethinking the relationship between nursing and diversity. American Journal of Nursing, 101(1), 63, 65. Krumberger, J. M. (2000). Critical care close-up. RN, 63(4), 24AC2– 24AC3. Kudzma, E. C. (1999). Culturally competent drug administration. American Journal of Nursing, 99(8), 46–51. Leininger, M. M. (1988). Leininger’s theory of nursing: Cultural care diversity and universality. Nursing Science Quarterly, 1(4), 152–159. National Institutes of Health, National Center for Complementary and Alternative Medicine (n.d.). Major domains of complementary & al-
ternative medicine. Available at: http://nccam.nih.gov/fcp/classify/. Accessed September 8, 2001. Palmer, J. (2001). Respecting tradition in healing. Reflections on Nursing Leadership, 27(2), 30–31. Suro, R. (2000). Beyond economics. American Demographics, 22(2), 48–55.
RESOURCES AND WEBSITES Organizations Asian-Pacific Islander Nurses Association, c/o College of Mount Saint Vincent, 6301 Riverdale Avenue, Riverdale, NY 10471; 1-718-4053354. Council on Nursing and Anthropology, c/o Dr. Mildred Roberson, Nursing and Health Sciences, Salisbury State University, Salisbury, MD 21801. National Alaska–Native American Indian Nurses Association, 3702 South Fife Street #55, K-2, Tacoma, Washington 98408-7318; 1-907-279-3303. National Association of Hispanic Nurses, 1501 16th Street NW, Washington, DC 20036; 1-202-387-2477; fax 202-483-7183; http://www. thehispanicnurses.org/. National Black Nurses Association, P.O. Box 1823, Washington, DC 20012-1823; 1-202-393-6870; fax 1-202-347-3808; http://www. nbna.org. National Gerontological Nursing Association, 7250 Parkway Dr., Suite 510 Hanover, MD 21076; 1-800-723-0560; fax 410-712-4424; e-mail:
[email protected]. National Institutes of Health, National Center for Complementary and Alternative Medicine, 6707 Democracy Blvd., Suite 2000, Bethesda, MD 20892-5475; 1-888-644-6226; fax 1-866-464-3616; http://nccam.nih.gov. Accessed 9/8/01. Office of Minority Health, U.S. Department of Health and Human Services, P.O. Box 37337, Washington, DC 20013-7337; 1-800-4446472; http://www.omhrc.gov. No cost for accessing database, information specialists, resource network, and publications on major health problems affecting African Americans, Hispanics, Native Americans, and Asian/Pacific Islanders. Transcultural Nursing Society, c/o Madonna University College of Nursing and Health, 36600 Schoolcraft Road, Livonia MI 481501173; 888-432-5470.
Translation Services AT&T Language Line Services; 1-800-752-6096. Provides written and oral translation in 140 languages.
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LEARNING OBJECTIVES
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On completion of this chapter, the learner will be able to: 1. Describe the role of the nurse in integrating genetics in nursing 2. 3. 4.
care. Conduct a genetics-based assessment. Identify the common patterns of inheritance of genetic disorders. Identify ethical issues in nursing related to genetics.
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uman genome discoveries have ushered in a new era of medicine, genomic medicine, which recognizes that multiple genes work in concert with environmental influences to cause disease. Genomic medicine aims to improve predictions about individuals’ susceptibility to diseases, the time of onset for those diseases, their extent and eventual severity, and which treatments or medications are likely to be most effective or harmful (Billings, 2000). Already, new gene-based strategies for disease detection, management, and treatment have been created, allowing health professionals to tailor care to an individual’s particular genetic make-up. To meet the challenges of genomic medicine, nurses need to understand the new technologies and treatments of gene-based health care. Nurses also must recognize that they are a vital link between patients and health care services; patients often turn to nurses first with questions about family history of risk factors, genetics information, and genetic tests and interpretations. Incorporating genetics into nursing means bringing a genetics framework to health assessments, planning, and interventions that supports identification of and response to individuals’ changing genetics-related health needs (Lea, Williams, Jenkins, et al., 2000).
Nurses must learn to recognize patterns of inheritance when obtaining family and medical histories and understand when it is appropriate to consider new gene-based testing and treatment options. This chapter offers a foundation for the clinical applications of genetics principles in medical and surgical nursing, outlines the nurse’s role in genetic counseling and evaluation, addresses important ethical issues, and provides genetics resources for nurses and patients.
A Framework for Integrating Genetics Into Nursing Practice Nursing’s unique contribution to genomic medicine is its philosophy of holism. Nurses are ideally positioned to incorporate genetics into their assessments, planning, and interventions for patients at different ages and stages across the lifespan and in all settings. The holistic view that characterizes nursing takes into account each person’s intellectual, physical, spiritual, social, cultural, biopsychologic, ethical, and esthetic experiences while ad-
Glossary allele: any one of two or more alternate forms of a gene at the same location. An allele for each gene is inherited from each parent. autosome: a single chromosome from any of the 22 pairs of chromosomes not involved in sex determination (XX or XY) carrier: person who is heterozygous; possessing two different alleles of a gene pair chromosome: microscopic structures in the cell nucleus that contain genetic information and are constant in number in a species (eg, humans have 46 chromosomes) deoxyribonucleic acid (DNA): the primary genetic material in humans consisting of nitrogenous bases, a sugar group, and phosphate combined into a double helix diploid: the number of chromosomes normally present in somatic cells. For humans, that number is 46. dominant: a genetic trait that is normally expressed when a person has a gene mutation on one of a pair of chromosomes and the “normal” form of the gene is on the other chromosome genetics: the scientific study of heredity; how specific traits or predispositions are transmitted from parents to offspring genome: the total genetic complement of an individual genotype genomics: the study of the human genome, including gene sequencing, mapping, and function genotype: the genes and the variations therein that a person inherits from his or her parents haploid: the number of chromosomes present in egg or sperm (gametes); in humans, this is 23 Human Genome Project: an international research effort aimed at identifying and
characterizing the order of every base in the human genome meiosis: the reduction division of diploid egg or sperm (germ cells) resulting in haploid gametes (having 23 chromosomes each) mitosis: cell division occurring in somatic cells that normally results in daughter cells with the same number of chromosomes— 46 (diploid) monosomy: missing one of a chromosome pair in normally diploid cells (for example, 45,X females have only one X chromosome) mutation: a heritable alteration in the genetic material nondisjunction: the failure of a chromosome pair to separate appropriately during meiosis, resulting in abnormal chromosome numbers in reproductive cells (gametes) or cells nucleotide: a nucleic acid “building block” composed of a nitrogenous base, a fivecarbon sugar, and a phosphate group pedigree: a diagrammatic representation of a family history penetrance: the percentage of individuals known to carry the gene for a trait who actually manifest the condition. For example, a trait with 90% penetrance will not be manifested by 10% of persons possessing the gene. phenotype: a person’s entire physical, biochemical, and physiological makeup, as determined by the individual’s genotype and environmental factors polymorphism: a genetic variation with two or more alleles that is maintained in a population population screening: the application of a test or inquiry to a group to determine if
individuals in the group have an increased likelihood of a genetic condition or a mutation in a specific gene (eg, cholesterol screening for hypercholesterolemia) predisposition testing: testing that is used to determine the likelihood that a healthy person with or without a family history of a condition will develop the disorder. Having the gene mutation would indicate that the person has an increased susceptibility to the disorder, but this is not a diagnosis. One example is DNA mutation testing for hereditary breast/ovarian cancer. prenatal screening: testing that is used to identify if a fetus is at risk for a birth defect such as Down syndrome or spina bifida (eg, multiple marker maternal serum screening in pregnancy) presymptomatic testing: genetic testing that is used to determine whether persons with a family history of a disorder, but no current symptoms, have the gene mutation. An example of this would be Huntington disease. recessive: a genetic trait that is expressed only when a person has two copies of a mutant autosomal gene or a single copy of a mutant X-linked gene in the absence of another X chromosome transcription: the process of transforming information from DNA into new strands of messenger RNA trisomy: the presence of one extra chromosome in an otherwise diploid chromosome complement—for example, trisomy 21 (Down syndrome) variable expression: variation in the degree to which a trait is manifested; clinical severity X-linked: located on the X chromosome
Chapter 9 dressing genetics information, gene-based testing, diagnosis, and treatments. Thus, knowledge about genetics is basic to nursing practice (Lea, Anderson & Monsen, 1998). A framework for integrating genetics into nursing practice includes a philosophy of care that recognizes when genetics factors are playing a role or could play a role in an individual’s health. This means using family history and the results of genetics tests effectively, informing patients about genetics concepts, understanding the personal and societal impact of genetics information, and valuing the privacy and confidentiality of genetics information. A person’s response to genetics information, genetic testing, or conditions may be either disabling or empowering. Genetics information may stigmatize individuals if it affects how they view themselves or how others view them. Nurses can help individuals and families understand the genetic aspect of themselves and learn how genetic traits and conditions are passed on within families and how genetic and environmental factors influence health and disease (Lea, Anderson & Monsen, 1998; Peters et al., 1999). Nurses facilitate communication among family members, the health care system, and community resources; they offer valuable support by virtue of their continuity of care with patients and families. All nurses should be able to recognize when a client is asking a question related to genetics information and should know how to obtain genetics information by gathering family and health histories and conducting physical and developmental
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assessments. Being able to recognize a genetics concern allows the nurse to provide appropriate genetics resources and support to individuals and families (Lea, Jenkins & Francomano, 1998). Key to nurses’ genetics framework is the awareness of one’s attitudes, experience, and assumptions about genetics concepts and how these are manifested in one’s own practice. Chart 9-1 offers insights on how nurses can conduct periodic self-assessments.
Genetics Concepts Scientists and philosophers have long speculated about heredity and developed theories to explain how traits are transmitted to offspring. Developments in technology and research have accelerated progress in our understanding of genetics, allowing scientists to better understand relatively rare diseases such as phenylketonuria (PKU) or hemophilia that are related to mutations of a single gene inherited in families. New technologies and tools allow scientists to characterize inherited metabolic variations that interact over time and lead to common diseases such as cancer, heart disease, and dementia. This transition from genetics to genomics highlights how our understanding of single genes and their individual functions has evolved to understanding how multiple genes act and control biologic processes. Most health conditions are now believed to be the result of a combination of genetic and environmental influences and interactions (Billings, 2000).
Examining Our Own Attitudes, Experiences, and Assumptions
Self-knowledge is one of the cornerstones to providing quality nursing care, and as practitioners, our attitudes and experiences have an impact on clinical practice. These attitudes emerge from social, cultural, and religious experiences in one’s personal life. Awareness of our own values, beliefs, and cultural perceptions not only is important to the nurse–patient relationship, but it is also the first step in developing a genetics framework. Periodic self-assessment can help maintain an effective framework as nurses update genetics knowledge and practice. Nurses can develop an awareness of their own attitudes, experiences, and assumptions about genetics concepts by considering the following: • One’s family’s beliefs or values about health. What are your family, religious, or cultural beliefs about the cause of illness? How have your values or biases influenced your understanding of genetic conditions? • One’s philosophical, theologic, cultural, and ethical perspectives related to health. How would these attitudes influence your own use of genetics information or services? What experiences have you had with people from different social, cultural, religious, or ethnic groups? How would you deliver genetics information to individuals from different social, cultural, or ethnic groups? Can you recognize when personal values or biases may affect or interfere with the delivery of genetics information? • One’s level of genetics expertise. Can you recognize the limitations of your own genetics experience and know when to refer patients for further genetics work-up? • One’s experience with birth defects, chronic illnesses, and genetic conditions. Do you have a family member or friend who has a genetic condition or disorder? Has your experience been that
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genetic disorders are disabling or empowering? Do you view a parent “at fault” for having a baby born with a birth defect or genetic condition? Do you advocate for fair access and other rights for individuals who have birth defects, genetic conditions, or other disabilities? One’s view of DNA (the most basic concept of who we are, since our genetic makeup is unlike that of any other person except an identical twin). What are your assumptions about DNA? For example, do you assume that the genetic component of “the self ” is a defective self? As another example, healthy carriers of genetic alterations that predispose them to develop certain diseases in the future now belong to a new class of “at risk” individuals. A person who is “at risk” is not ill at present, but may not remain well as long as the “average” person. Is it good to know that you are “at risk” or is this information that should not be identified or revealed because of the risk of potential discrimination? One’s beliefs about reproductive options. What are your beliefs regarding reproductive options such as prenatal diagnosis and pregnancy termination? How might these influence your care of a patient who holds different beliefs? One’s view of genetic testing and engineering. Do you see genetic testing and engineering—the ability to eliminate or enhance certain traits—as a way to create an “ideal genetic self ”? One’s approach to patients with disabilities. How are your attitudes made apparent in your practice and practice settings? For example, do you have access to TTY machines and/or interpreters for those who have hearing impairment? Are your intake procedures adapted to meet the needs of an individual with disabilities?
Sources: National Coalition of Health Professional Education in Genetics (2001). Core competencies; http://www.nchpeg.org; Kenan, R. (1996). The at-risk health status and technology: A diagnostic invitation and the gift of knowing. Social Science and Medicine, 42(11), 1545–1553; Peters, J. A., Djurdjinovic, L. & Baker, D. (1999). The genetic self: The Human Genome Project, genetic counseling and family therapy. Families, Systems & Health, 17(1), 5–25.
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GENES AND THEIR ROLE IN HUMAN VARIATION Genes are central components of human health and disease. Work on the Human Genome Project (an international research effort to map and sequence the human genome in its entirety) has shown how basic human genetics is to human development, health, and disease. Knowledge that specific genes are associated with specific genetic conditions makes diagnosis possible, even in the unborn. Research continues to demonstrate how many common conditions have genetic causes. Many more associations between genetics, health, and disease will likely be identified as scientists complete and refine human genome mapping and sequencing.
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Genes and Chromosomes A person’s unique genetic constitution, called a genotype, is made up of some 30,000 to 40,000 genes. A person’s phenotype, the observable characteristics of his or her genotype, includes physical appearance and other biologic, physiologic, and molecular traits. Environmental influences modify every individual’s phenotype, even those with a major genetic component. Human growth, development, and disease occur as a result of both genetic and environmental influences and interactions. The contribution of genetic factors may be large or small. For example, in a person with cystic fibrosis or PKU, the genetic contribution is significant. In contrast, the genetic contribution underlying a person’s response to infection may be less so. An individual gene is conceptualized as a unit of heredity. A gene is composed of a segment of deoxyribonucleic acid (DNA) that contains a specific set of instructions for making the protein or proteins needed by body cells for proper functioning. Genes regulate both the types of proteins made and the rate at which proteins are produced. The structure of the DNA molecule is referred to as the double helix. The essential components of the DNA molecule are sugar-phosphate molecules and pairs of nitrogenous bases. Each nucleotide contains a sugar (deoxyribose), a phosphate group, and one of four nitrogenous bases: adenine (A), cytosine (C), guanine (G), and thymine (T). DNA is composed of two-paired strands, each made up of a number of nucleotides. The strands are held together by hydrogen bonds between pairs of bases (Fig. 9-1). Genes are packaged and arranged in a linear order within chromosomes, which are located in the cell nucleus. In humans, 46 chromosomes occur in pairs in all body cells except oocytes (eggs) and sperm, which each contain only 23 chromosomes. Twenty-two pairs of chromosomes, called autosomes, are the same in females and males. The 23rd pair is referred to as the sex chromosomes. A female has two X chromosomes, while a male has one X and one Y chromosome. At conception, each parent normally gives one chromosome of each pair to his or her children. As a result, children receive half of their chromosomes from their fathers and half from their mothers (Fig. 9-2). Careful examination of DNA sequences from many individuals shows that these sequences have multiple versions in a population. These different versions, or sequence variations, are called alleles. Sequences found in many forms are said to be polymorphic, meaning that there are at least two common forms of a particular gene.
DNA molecule
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FIGURE 9-1 DNA that carries the instructions that allow cells to make proteins is made up of four chemical bases. Tightly coiled strands of DNA are packaged in units called chromosomes, housed in the cell’s nucleus. Working subunits of DNA are known as genes. From the National Institutes of Health and National Cancer Institute. (1995). Understanding gene testing (NIH Pub. No. 96-3905). Washington, DC: U.S. Department of Human Services.
Cell Division The human body grows and develops through a process of cell division. Mitosis and meiosis, two distinctly different types of cell division, contribute to these processes. Mitosis is the process of cell division involved in cell growth, differentiation, and repair. During mitosis, the chromosomes of each cell duplicate. The result is two cells, called daughter cells, each containing the same number of chromosomes as the parent cell. The daughter cells are said to be diploid because they contain 46 chromosomes in 23 pairs. Mitosis occurs in all cells of the body except oocytes (eggs) and sperm. Meiosis, in contrast, occurs only in reproductive cells and is the process by which oocytes and sperm are formed. During meiosis a reduction in the number of chromosomes takes place, resulting in oocytes or sperm that contain half the usual number or 23 chromosomes. Oocytes and sperm are referred to as haploid because they contain a single copy of each chromosome, compared to the usual two chromosomes in all other body cells.
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individual with Down syndrome has three number 21 chromosomes. Turner syndrome is an example of monosomy. Girls who have Turner syndrome usually have a single X chromosome, causing them to have short stature and infertility (Lashley, 1998).
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FIGURE 9-2 Each human cell contains 23 pairs of chromosomes, which can be distinguished by size and by unique banding patterns. This set is from a male, since it contains a Y chromosome. Females have two X chromosomes. From the National Institutes of Health and National Cancer Institute. (1995). Understanding gene testing (NIH Pub. No. 96-3905). Washington, DC: U.S. Department of Human Services. During the initial phase of meiosis, paired chromosomes come together in preparation for cell division, portions cross over, and an exchange of genetic material occurs. This event, called recombination, creates greater diversity in the makeup of oocytes and sperm. During meiosis, a pair of chromosomes may fail to separate completely, creating a sperm or oocyte that contains either two copies or no copy of a particular chromosome. This sporadic event, called nondisjunction, can lead to either a trisomy or a monosomy. Down syndrome is an example of trisomy. An
Nucleus
Within each cell, many intricate and complex interactions regulate and express human genes. Gene structure and function, transcription and translation, and protein synthesis are all involved. Alterations in gene structure and function and the process of protein synthesis may influence a person’s health. Changes in gene structure, called mutations, permanently change the sequence of DNA, which in turn can alter the nature and type of proteins made (Fig. 9-3). Some gene mutations have no significant effect on the protein product made, while others cause partial or complete changes. How a protein is altered and its importance to proper body functioning determine the mutation’s impact. Gene mutations may occur in hormones or enzymes or important protein products, thereby having significant implications for health and disease. Sickle cell anemia is an example of a genetic condition caused by a small gene mutation that affects protein structure, producing hemoglobin S. A person who inherits two copies of the hemoglobin S gene mutation has the condition sickle cell anemia and experiences the symptoms of severe anemia and thrombotic organ damage resulting from hypoxia (Lashley, 1998; Lea, 2000). Other gene mutations may be larger, such as a deletion (loss), insertion (addition), duplication (multiplication), or rearrangement (translocation) of a longer DNA segment. Duchenne muscular dystrophy, an inherited form of muscular dystrophy, is an example of a genetic disorder caused by structural gene mutations such as deletions or duplications in the dystrophin gene. Another type of gene mutation, called a triplet or trinucleotide repeat, involves the expansion of more than the usual number of a triplet
DNA
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FIGURE 9-3
When a gene contains a mutation, the protein encoded by that gene will be abnormal. Some protein changes are insignificant, others are disabling. From the National Institutes of Health and National Cancer Institute. (1995). Understanding gene testing (NIH Pub. No. 96-3905). Washington, DC: U.S. Department of Human Services.
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repeat sequence within a gene. Myotonic dystrophy, Huntington disease, and fragile X syndrome are examples of conditions caused by this type of gene mutation. Gene mutations may be inherited or acquired. Inherited or germ-line gene mutations are present in the DNA of all body cells and are passed on in reproductive cells from parent to child. Germ-line mutations are passed on to all daughter cells when body cells replicate (Fig. 9-4). The gene that causes Huntington disease is one example of a germ-line mutation. Spontaneous gene mutations take place in individual oocytes or sperm at the time of conception. These mutations are not inherited in other family members. A person who carries the new “spontaneous” mutation, however, may pass on the gene mutation to his or her children. Achondroplasia, Marfan syndrome, and neurofibromatosis type 1 are examples of genetic conditions that may occur in a single family member as a result of spontaneous mutation. Acquired mutations take place in somatic cells and involve changes in DNA that occur after conception, during a person’s lifetime. Acquired mutations develop as a result of cumulative changes in body cells other than reproductive cells (Fig. 9-5). Somatic gene mutations are passed on to the daughter cells derived from that particular cell line. Gene mutations occur in the human body all the time. Cells have built-in mechanisms by which they can recognize mutations in DNA, and in most situations they correct the change before it is passed on by cell division. However, over time, body cells may lose their ability to repair damage from gene mutations, causing an accumulation of genetic changes that may ultimately result in diseases such as cancer and possibly other conditions of aging, such as Alzheimer’s disease (Lashley, 1998).
Genetic Variation Sorting out the genetic components of complex conditions (eg, heart disease, diabetes, common cancers, psychiatric disorders) that result from the interaction of environment, lifestyle, and the small effects of many genes is ongoing. New studies of genetic
variation in humans are underway to develop a map of common DNA variants. Genetic variations occur among individuals of all populations. Polymorphisms and single nucleotide polymorphisms (SNPs, pronounced “snips”) are the terms used for common genetic variations that occur most frequently throughout the human genome. Some SNPs may contribute directly to a trait or disease expression by altering function. SNPs are becoming increasingly important for the discovery of DNA sequence variations that affect biologic function. Such knowledge will allow clinicians to subclassify diseases and adapt therapies to the individual patient (Collins, 1999; Collins & McKusick, 2001). For example, a polymorphism or SNP can alter a protein or enzyme activity and can thus affect drug efficacy and safety when it occurs in proteins that are targets of medication regimens or that are involved in drug transport or drug metabolism (McCarthy & Hilfiker, 2000; Schafer & Hawkins, 1998).
INHERITANCE PATTERNS IN FAMILIES Nursing assessment of patients’ health includes obtaining and recording family history information. Family history evaluation in the form of a pedigree is a first step in establishing the pattern of inheritance. Nurses must become familiar with mendelian patterns of inheritance and pedigree construction and analysis to be able to help identify individuals and families who may benefit from further genetic counseling, testing and therapeutics (Lea, Jenkins & Francomano, 1998; Lea, 2000). Mendelian conditions are genetic conditions that are inherited in families in fixed proportions among generations. Named after Gregor Mendel, mendelian conditions result from gene mutations present on one or both chromosomes of a pair. An individual gene inherited from one or both parents can cause a mendelian inherited condition. Mendelian conditions are classified according to their pattern of inheritance in families: autosomal dominant, autosomal recessive, and X-linked. The terms dominant and recessive refer to the trait, genetic condition, or phenotype, but not to the genes or alleles that cause the observable characteristics (Thompson et al., 2001).
Sperm
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FIGURE 9-4 Hereditary mutations are carried in the DNA of the reproductive cells. When reproductive cells containing mutations combine to produce offspring, the mutation will be present in all of the offspring’s body cells. From the National Institutes of Health and National Cancer Institute. (1995). Understanding gene testing (NIH Pub. No. 96-3905). Washington, DC: U.S. Department of Human Services.
Chapter 9 Normal bone cell
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FIGURE 9-5
Acquired mutations develop in DNA during a person’s lifetime. If the mutation arises in a body cell, copies of the mutation will exist only in the descendants of that particular cell. From the National Institutes of Health and National Cancer Institute. (1995). Understanding gene testing (NIH Pub. No. 96-3905). Washington, DC: U.S. Department of Human Services.
Autosomal Dominant Inheritance Autosomal dominant inherited conditions affect female and male family members equally and follow a vertical pattern of inheritance in families (Fig. 9-6). An individual who has an autosomal dominant inherited condition carries a gene mutation for that condition on one chromosome of a pair. Each of that individual’s offspring has a 50% chance of inheriting the gene mutation for the condition and a 50% chance of inheriting the normal version of the gene. Offspring who do not inherit the gene mutation for the dominant condition will not develop the condition and do not have an increased chance for having chil-
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dren with the same condition (Fig. 9-7). Table 9-1 presents characteristics and examples of different patterns of inherited conditions. Autosomal dominant inherited conditions often present with varying degrees of severity among affected family members and persons. Some individuals with the condition may have significant symptoms, while others may have only mild ones. This characteristic is referred to as variable expression; it results from the influences of genetic and environmental factors on clinical presentation. Another phenomenon observed in autosomal dominant inheritance is penetrance, the percentage of persons known to have a particular gene mutation who actually show the trait. Penetrance is observed in conditions such as achondroplasia, in which nearly 100% of persons with the gene mutation typically display traits of the disease. In some conditions, the presence of a gene mutation does not invariably mean that a person will have or develop an autosomal inherited condition. For example, a woman who has the BRCA1 hereditary breast cancer gene mutation has a lifetime risk for breast cancer up to 80%, not 100%. This quality, known as incomplete penetrance, indicates the probability that a given gene will produce disease. In other words, a person may inherit the gene mutation that causes an autosomal dominant condition but may not have any of the observable physical or developmental features of that condition. However, these individuals carry the gene mutation and still have a 50% chance of passing the gene for the condition to each of their children. One of the effects of incomplete penetrance is that the gene appears to “skip” a generation, thus leading to errors in interpreting family history and in genetic counseling. Examples of other genetic conditions with incomplete pene-
Affected father
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FIGURE 9-6 inheritance.
Three-generation pedigree illustrating autosomal dominant
Normal daughter
FIGURE 9-7 In dominant genetic disorders, if one affected parent has a disease-causing allele that dominates its normal counterpart, each child in the family has a 50% chance of inheriting the disease allele and the disorder. From the National Institutes of Health and National Cancer Institute. (1995). Understanding gene testing (NIH Pub. No. 96-3905). Washington, DC: U.S. Department of Human Services.
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• Patterns of Mendelian Inheritance
CHARACTERISTICS
Autosomal Dominant Inherited Conditions Vertical transmission in families Males and females equally affected Variable expression among family members and others with condition Reduced penetrance (in some conditions) Advanced paternal age associated with sporadic cases Autosomal Recessive Inherited Conditions Horizontal pattern of transmission seen in families Males and females equally affected Associated with consanguinity (genetic relatedness) Associated with particular ethnic groups
X-Linked Recessive Inherited Conditions Vertical transmission in families Males predominantly affected
Multifactorial Inherited Conditions Occur as a result of genetic and environmental factors combining May recur in families Inheritance pattern does not demonstrate the characteristic pattern of inheritance seen with other mendelian inherited conditions
EXAMPLES
Hereditary breast/ovarian cancer syndrome Familial hypercholesterolemia Hereditary non-polyposis colorectal cancer Huntington disease Marfan syndrome Neurofibromatosis Cystic fibrosis Galactosemia Phenylketonuria Sickle cell anemia Tay-Sachs disease Canavan disease Duchenne muscular dystrophy Hemophilia A and B Wiscott-Aldrich syndrome Protan and Deutran forms of color blindness Congenital heart defects Cleft lip and/or palate Neural tube defects (anencephaly and spina bifida) Diabetes mellitus Osteoarthritis High blood pressure
Adapted from Lea, D. H., Jenkins, J. F., & Francomano, C. A. (1998). Genetics in clinical practice: New directions for nursing and health care. Sudbury, MA: Jones & Bartlett; Lea, D. H. (2002). Genetics. In Maher, A. B., Salmond, S. W., & Pellino, T. A. (Eds.) Orthopaedic nursing. Philadelphia: W. B. Saunders.
trance include otosclerosis (40%) and retinoblastoma (80%) (Lashley, 1998).
Autosomal Recessive Inheritance The pattern of inheritance in autosomal recessive inherited conditions differs from that of autosomal dominant inherited conditions in that it is more horizontal than vertical, with relatives of a single generation tending to have the condition (Fig. 9-8). Genetic conditions inherited in an autosomal recessive pattern are frequently seen among particular ethnic groups and tend to occur more often in children of parents who are related by blood, such as first cousins (see Table 9-1). In autosomal recessive inheritance, each parent carries a gene mutation on one chromosome of the pair and the normal working copy of the gene on the other chromosome. The parents are said to be carriers of the particular gene mutation. Unlike an individual with an autosomal dominant inherited condition, a carrier of a gene mutation for a recessive inherited condition does not have symptoms of the genetic condition. When two carrier parents have children together, they have (with each of their pregnancies) a 25% chance of having a child who inherits the gene mutation from each parent and who will have the condition (Fig. 9-9).
for a normal sex constitution of 46,XY. Since males have only one X chromosome, they do not have a counterpart for its genes as do females. This means that a gene mutation on their X chromosome is expressed when present in one copy. A female, on the other hand, inherits one X chromosome from each parent for a normal sex constitution of 46,XX. A female may be a carrier of
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X-Linked Inheritance X-linked conditions may be inherited in families in recessive or dominant patterns (see Table 9-1). In both, the gene mutation is located on the X chromosome. All males inherit an X chromosome from their mother and a Y chromosome from their father
FIGURE 9-8 inheritance.
Three-generation pedigree illustrating autosomal recessive
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FIGURE 9-10
Three-generation pedigree illustrating X-linked recessive
inheritance. Normal son
Carrier daughter
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FIGURE 9-9 In diseases associated with altered recessive genes, both parents—though disease-free themselves—carry one normal allele and one altered allele. Each child has one chance in four of inheriting two altered alleles and developing the disorder; one chance in four of inheriting two normal alleles; and two chances in four of inheriting one normal and one altered allele, and being a carrier like both parents. From the National Institutes of Health and National Cancer Institute. (1995). Understanding gene testing (NIH Pub. No. 96-3905). Washington, DC: U.S. Department of Human Services.
a gene mutation or affected if the condition results from a gene mutation causing a dominant X-linked condition. Either the X chromosome that a female receives from her mother or the X chromosome she receives from her father may be passed on to her sons, and this is a random occurrence. The most common pattern of X-linked inheritance is that in which a female is a carrier for a gene mutation on one of her X chromosomes. This is referred to as X-linked recessive inheritance. In X-linked recessive inherited conditions, a female carrier has a 50% chance to pass on the gene mutation to a son, who would be affected, or to a daughter, who would be a carrier like her mother (Fig. 9-10).
Nontraditional Inheritance Patterns Although mendelian inherited conditions present with a specific pattern of inheritance in some families, many diseases and traits do not follow these simple patterns. A variety of factors influence how a gene performs and is expressed. Different mutations in the same gene can produce variable symptoms in different individuals, as is the case with cystic fibrosis. Different mutations in several genes can lead to the identical outcome, as observed with Alzheimer’s disease. Some traits involve the simultaneous mutation in two or more genes. A recently observed phenomenon, imprinting, can determine which pair of genes (the mother’s or the father’s) will be silenced or activated. This form of inheritance has been observed in Angelman syn-
drome, a severe form of mental retardation and ataxia (Thompson et al., 2001).
Multifactorial and Complex Genetic Conditions Many birth defects and common health conditions such as heart disease, high blood pressure, cancer, osteoarthritis, and diabetes occur as a result of interactions of multiple gene mutations and environmental influences, and thus are called multifactorial or complex conditions (see Table 9-1). Multifactorial conditions may cluster in families but do not present with the characteristic pattern of inheritance seen in families having mendelian inherited conditions (Fig. 9-11). Neural tube defects, such as spina bifida and anencephaly, are examples of multifactorial genetic conditions (Chart 9-2).
I
II
III
Unaffected male Unaffected female Affected male
FIGURE 9-11 conditions.
Three-generation pedigree illustrating multifactorial
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Chart 9-2
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Neural Tube Defects and Folic Acid
Most neural tube defects are caused by both genetic and environmental influences that combine during early embryonic development, leading to incomplete closure of the neural tube. More rarely, chromosomal abnormalities such as trisomy 18 or prenatal exposure to certain medications such as valproic acid are the underlying cause of neural tube defects. Research has shown that folic acid taken in the prescribed amount of 4.0 mg daily prior to conception and during the first 3 months of pregnancy reduces the recurrence of neural tube defects by 70% in women who have had a previously affected pregnancy. It is now recommended that all women in childbearing years take folic acid (0.4 mg) daily as part of a multivitamin to decrease the risk for neural tube defects (Centers for Disease Control and Prevention, 1992; Hall & Solehdin, 1998). Folic acid is recognized as an important environmental element that plays a critical role in fetal development and influences the outcome of genetic susceptibility to neural tube defects.
CHROMOSOMAL DIFFERENCES AND GENETIC CONDITIONS Differences in the number or structure of chromosomes are a major cause of birth defects, mental retardation, and malignancies. Chromosomal differences are present in approximately 1 in every 160 live-born infants and are the cause of greater than 50% of all spontaneous first-trimester pregnancy losses (Lashley, 1998; Thompson et al., 2001). Chromosomal differences most commonly involve an extra or missing chromosome. This is called aneuploidy. Whenever there is an extra or missing chromosome, there is always associated mental or physical disability to some degree. Down syndrome, or trisomy 21, is a common chromosomal condition that occurs with greater frequency in pregnancies of women who are 35 years or older. A person who has trisomy 21 Down syndrome has a complete extra number 21 chromosome, which causes a particular facial appearance and increased risk for congenital heart defects, thyroid and vision problems, and mental retardation. Other examples of chromosomal differences include trisomy 13 and 18, both more severe than Down syndrome, and conditions involving extra or missing sex chromosomes (eg, Turner syndrome, in which females have only one X chromosome instead of the usual two) (Lashley, 1998). Chromosomal differences may also involve a structural rearrangement within or between chromosomes. These are less common than chromosomal conditions in which there is an extra or missing chromosome, but occur in 1 in every 500 newborns (Thompson et al., 2001). People who carry “balanced” chromosome rearrangements have all of their chromosomal material, but it is rearranged. A person who carries a balanced chromosomal rearrangement has an increased risk for spontaneous pregnancy loss and for having children with an unbalanced chromosomal arrangement that may result in physical or mental disabilities. Known carriers are therefore offered prenatal counseling and testing. Chromosome studies may be needed at any age, depending upon the indication. Two common indications are for confirmation of a suspected diagnosis such as Down syndrome, and for a history of two or more unexplained pregnancy losses. Chromosome studies are accomplished by obtaining a tissue sample (eg, blood, skin, amniotic fluid), preparing and staining the chromosomes, and analyzing them under a microscope. The microscopic study
of chromosomes is called cytogenetics and is an area that is rapidly evolving. Today, cytogenetics is used with new molecular techniques such as fluorescent in situ hybridization (FISH), which permits more detailed examination of chromosomes. FISH is useful to detect small abnormalities, including characterizing chromosomal rearrangements (Thompson et al., 2001).
Clinical Applications of Genetics One of the most immediate applications of new genetics discoveries is the development of genetic tests that can be used to detect a trait, diagnose a genetic condition, and identify people who have a genetic predisposition to a disease such as cancer or heart disease. Another emerging application is pharmacogenetics. Pharmacogenetics involves the use of genetic testing to identify genetic variations that relate to the safety and efficacy of medications and gene-based treatments, so that individualized treatment and management plans can be developed. Future applications may include the use of gene chips to map a person’s individual genome for genetic variations that may lead to disease. Nurses will be involved in caring for patients who are undergoing genetic testing and gene-based treatments. Knowledge of the clinical applications of modern genetics technologies will prepare nurses to inform and support patients, and to provide high-quality genetics-related health care.
GENETIC TESTING Genetic tests provide information leading to the diagnosis of inherited conditions or other conditions with a known genetic contribution. Genetic testing involves the use of specific laboratory analyses of chromosomes, genes, or gene products (eg, enzymes, proteins) to learn whether a genetic alteration related to a specific disease or condition is present in an individual. Genetic testing can be DNA-based, chromosomal or biochemical. There are several important uses for genetic testing, as identified by the Secretary’s Advisory Committee on Genetic Testing (SACGT, 2000). Prenatal testing includes all three types of genetic testing (DNA-based, chromosomal and biochemical) and is widely used for prenatal screening and diagnosis of such conditions as Down syndrome. Carrier testing is used to determine carrier status, helping couples or individuals learn whether they carry a recessive allele for an inherited condition (eg, cystic fibrosis, sickle cell anemia, or Tay-Sachs disease) and thus risk passing it on to their children. Genetic testing is also used widely in newborn screening, and in the United States is made available for an increasing number of genetic conditions. Two examples are PKU and galactosemia. Diagnostic testing is used to detect the presence or absence of a particular genetic alteration or allele to identify or confirm a diagnosis of a disease or condition in an affected individual—for example, myotonic dystrophy and fragile X syndrome. In the near future, genetic tests will be increasingly used to identify a person’s predisposition to disease and to design specific and individualized treatment and management plans. Examples of current uses of genetic tests are shown in Table 9-2. Nurses will increasingly participate in genetic testing, especially in the areas of patient education, ensuring informed health choices and consent, advocating for privacy and confidentiality with regard to genetic test results, and assisting patients to understand the complex issues involved in genetic testing (Lea & Williams, 2002).
Chapter 9
Table 9-2
Genetics Perspectives in Nursing
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• Genetic Tests: Examples of Current Uses
PURPOSE OF GENETIC TEST
Carrier Testing Cystic fibrosis Tay-Sachs disease Canavan disease Sickle cell anemia Thalassemia Prenatal Diagnosis—amniocentesis is often performed when there is a risk for a chromosomal or genetic disorder: Risk for Down syndrome Risk for cystic fibrosis Risk for Tay-Sachs disease Risk for open neural tube defect Diagnosis Down syndrome Fragile X syndrome Myotonic dystrophy Presymptomatic Testing Huntington disease Myotonic dystrophy Susceptibility Testing Hereditary breast/ovarian cancer Hereditary non-polyposis colorectal cancer
GENETIC SCREENING Genetic screening, in contrast to genetic testing, is a broader concept and applies to testing of populations or groups independent of a positive family history or symptom manifestation. Genetic screening, as defined in 1975 by the Committee for the Study of Inborn Errors of Metabolism of the National Academy of Sciences (SACGT, 2000), has several major aims. One is management; that is, identifying people with treatable genetic conditions that could prove dangerous to their health if left untreated. An example of this is screening of newborns. A second aim is to provide reproductive options to people with a high probability of having children with severe, untreatable diseases and for whom genetic counseling, prenatal diagnosis, and other reproductive options could be helpful and of interest. This is illustrated by the screening of individuals of Ashkenazi Jewish descent for conditions such Tay-Sachs disease and Canavan disease. A third aim is screening pregnant women to detect birth defects such as neural tube defects and Down syndrome using multiple marker screening. Genetic screening may also be used for public health purposes to determine the incidence and prevalence of a birth defect, or to investigate the feasibility and value of new genetic testing methods. Most commonly genetic screening occurs in prenatal and newborn programs that involve nurses in various roles and settings. However, it is anticipated that genetic screening will expand in the future to include adult-onset conditions such as cancer, heart disease, diabetes, and hemochromatosis. Table 9-3 gives examples of genetic screening applications. In the future, population-based (widespread) genetic screening will be applied to help identify people who are predisposed to de-
TYPE OF GENETIC TEST
DNA analysis Hexosaminidase A activity testing and DNA analysis DNA analysis Hemoglobin electrophoresis Complete blood count and hemoglobin electrophoresis
Chromosomal analysis DNA analysis Hexosaminidase A activity testing and/or DNA analysis Protein analysis Chromosomal analysis DNA analysis DNA analysis DNA analysis DNA analysis DNA analysis DNA analysis
velop conditions such as breast and colon cancer and heart disease. Nurses will be expected to participate in explaining genetics concepts such as risk and genetic predisposition, supporting informed health decisions and opportunities for prevention and early intervention, and protecting patients’ privacy (Lea & Williams, 2002).
TESTING AND SCREENING FOR ADULT-ONSET CONDITIONS Adult-onset conditions are disorders with a genetic component that are manifested in later life. Often symptoms or clinical manifestations occur only in late adolescence or adulthood, and disease is clearly observed to run in families. Some of these conditions are attributed to specific genetic mutations following either autosomal dominant inheritance or autosomal recessive inheritance. However, the majority of adult-onset conditions are considered to be multifactorial (polygenetic) in nature (eg, heart disease, diabetes, arthritis). Nursing assessment for adult-onset conditions is based on the family history and the identification of diseases or clinical manifestations associated with adult- onset conditions. Knowledge of adult-onset conditions and their genetic basis (ie, mendelian versus multifactorial conditions) influences the nursing considerations for genetic testing. Table 9-4 describes adult-onset conditions, their age of onset, pattern of inheritance, genes involved, and testing availability. If a single gene accounts for an adult-onset condition in a symptomatic individual, diagnostic testing is used to confirm a diagnosis to assist in the plan of care and management. Diagnostic testing for adult-onset conditions is most frequently used with autosomal dominant conditions, such as Huntington disease or
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Table 9-3
• Applications for Genetic Screening
TIMING OF SCREENING
PURPOSE
EXAMPLES
Preconception screening
For autosomal recessive inherited genetic conditions that occur with greater frequency among individuals of certain ethnic groups
Prenatal screening
For genetic conditions that are common and for which prenatal diagnosis is available when a pregnancy is identified at increased risk For genetic conditions for which there is specific treatment
Cystic fibrosis—all couples, but especially Northern European Caucasian, and Ashkenazi Jewish Tay-Sachs disease—Ashkenazi Jewish Sickle cell anemia—African American, Puerto Rican, Mediterranean, Middle Eastern Alpha-thalassemia—Southeast Asian, African American Neural tube defects—spina bifida, anencephaly Down syndrome Other chromosomal abnormalities— trisomy 18
Newborn screening
Factor V Leiden thrombophilia, and autosomal recessive conditions, such as hemochromatosis. In families with known adultonset conditions or with a confirmed genetic mutation in an affected family member, presymptomatic testing provides asymptomatic individuals with information about having a genetic mutation and about the likelihood of developing the disease. Huntington disease has served as the model for presymptomatic testing because the presence of the genetic mutation predicts disease onset and progression. Although preventive measures are not yet available for Huntington disease, the genetics information enables health care providers to develop a clinical, supportive, and psychological plan of care. Presymptomatic testing is considered for families with a known adult-onset condition in which either a positive or negative result will affect medical management or in which earlier treatment of a condition is more beneficial than treatment at a later stage. Presymptomatic testing is therefore offered for several adult-onset conditions, such as cancer, thrombophilia, and antitrypsin deficiency. In the absence of a single disease-causing gene, it is thought that multiple genes are related to the onset of most adult diseases. These susceptibility genes modify or influence the development and severity of disease. Most susceptibility testing is conducted in the research setting to identify candidate genes for disease, such as Alzheimer’s, psychiatric conditions, heart disease, hypertension, and hypercholesterolemia. For some diseases, the interaction of several genes and other environmental or metabolic events affect disease onset and progression. Susceptibility testing can help to distinguish variations within the same disease or response to treatment. For example, no single gene is associated with osteoporosis. Several polymorphisms on candidate genes related to the vitamin D receptor, estrogen and androgen receptors, cytokine production and its associated stimulation of osteoclasts, and collagen type 1-alpha 1 are under study to predict bone mineral density and fracture risk. Some susceptibility genes may predict treatment response. For example, individuals can present with similar clinical signs and symptoms of asthma but have different responses to treatment. Susceptibility testing can help classify the asthma as sensitive or resistant to treatment with corticosteroids.
Phenylketonuria (PKU) Galactosemia Homocystinuria Biotinidase deficiency
Population screening, the use of genetic testing for large groups or whole populations, to identify late-onset conditions is under development. Currently population screening is offered in some ethnic groups to identify cancer-predisposing genes. For example, Ashkenazi Jewish individuals (Jews of Eastern European origin) have a greater chance of having inherited a specific genetic mutation in the BRCA1 or BRCA2 genes. Individuals with one of these BRCA mutations have approximately a 56% risk for breast cancer, 16% risk for ovarian cancer, and 16% risk for prostate cancer by age 70 (Struewing et al., 1997). Therefore, identifying one of these mutations allows the patient the options of cancer screening as well as other medical management such as chemoprevention or prophylactic mastectomy or oophorectomy in carriers. Population screening is being explored for other adultonset conditions such as type 2 diabetes and hereditary hemochromatosis (iron overload disorder). For a test to be considered for population screening, there must be: (1) sufficient information about gene distribution within populations, (2) accurate prediction about the development and progression of disease, and (3) appropriate medical management for asymptomatic individuals with a mutation (U.S. Preventive Services Task Force, 1996).
Nursing Considerations for Adult-Onset Conditions Nurses must be alert for family histories that indicate multiple generations (autosomal dominant inheritance) or multiple siblings (autosomal recessive inheritance) affected with the same condition, or onset of disease earlier than expected in the general population (eg, multiple generations with early-onset hyperlipidemia). Possible adult-onset conditions are discussed with other members of the health care team for appropriate resources and referral. Information about diagnostic testing is often introduced as part of a diagnostic work-up. The nurse supports the patient in making decisions related to genetic testing and provides referrals for appropriate education and counseling about the adult-onset condition prior to genetic testing. The nurse addresses the patient’s questions or concerns about the benefits and limitations of
Chapter 9
Table 9-4
Genetics Perspectives in Nursing
135
• Adult-Onset Disorders
CLINICAL DESCRIPTION
Early-onset familial Alzheimer’s disease Progressive dementia, memory failure, personality disturbance, loss of intellectual functioning associated with cerebral cortical atrophy, beta-amyloid plaque formation and intraneuronal neurofibrillary tangles Late-onset familial Alzheimer’s disease Progressive dementia, cognitive decline Frontotemporal dementia with parkinsonism—linked to chromosome 17 Dementia and/or parkinsonism. Slowly progressive behavioral changes, language disturbances and/or extrapyramidal signs and symptoms, rigidity, bradykinesia, and saccadic eye movements Huntington disease Widespread degenerative brain change with progressive motor loss both voluntary and involuntary disability, cognitive decline, chorea (involuntary movements) at later stage, psychiatric disturbances Neuromuscular disorders Spinocerebellar ataxia type 6 Slowly progressive cerebellar ataxia, dysarthria, and nystagmus Spinocerebellar ataxia type 1 Ataxia, dysarthria, and bulbar dysfunction Spinocerebellar ataxia type 2 Slow saccadic eye movement, peripheral neuropathy, decreased deep tendon reflexes, dementia Spinocerebellar ataxia type 3 Progressive cerebellar ataxia and variety of other neurologic symptoms including dystonic-rigid syndrome, parkinsonian syndrome or combined dystonia and peripheral neuropathy Mild myotonic muscular dystrophy Cataracts and myotonia or muscle wasting and weakness, frontal balding, and ECG changes (heart block or arrhythmia), diabetes mellitus in 5% of all cases Amyotrophic lateral sclerosis (ALS) Progressive loss of motor function with predominantly lower motor neuron manifestations Hematologic conditions Hereditary hemochromatosis High absorption of iron by GI mucosa resulting in excessive iron storage in liver, skin, pancreas, heart, joints and testes. Abdominal pain, weakness, lethargy, weight loss are early symptoms. Untreated individuals can present with skin pigmentation, diabetes mellitus, hepatic fibrosis or cirrhosis, heart failure, dysrhythmias or arthritis. Factor V Leiden thrombophilia Poor anticoagulant response to activated protein C with increased risk for venous thromboembolism and risk for increased fetal loss during pregnancy Polycystic kidney disease dominant Most common genetic disease in humans. Manifests with renal cysts, liver cysts, and occasionally intracranial and aortic aneurysm and hypertension. Loss of glomerular filtration can lead to kidney failure. Diabetes mellitus type II Insulin resistance and impaired glucose tolerance
AGE OF ONSET
60–65 years
Presymptomatic
40–60 years
A.D.
Research
Mean age 35–44 years
A.D.
Diagnostic and presymptomatic
Mean age 43–52 years
A.D.
Diagnostic and presymptomatic
Mean age 30–40 years
A.D.
Diagnostic and presymptomatic
Mean age 30–40 years
A.D.
Diagnostic and presymptomatic
Mean age 30s
A.D.
Diagnostic and presymptomatic
20–70 years
A.D. with variable penetrance
Research
50–70 years
Both A.D. and A.R.
Research
40–60 in males; after menopause in females
A.R.
Diagnostic and presymptomatic
30s; during pregnancy in females
A.D.
Diagnostic and presymptomatic
Variable onset—all carriers have detectable disease by ultrasound at age 30
A.D.
Diagnostic and presymptomatic
Variable onset— most often >30
M.F.
Research (continued)
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• Adult-Onset Disorders (Continued)
CLINICAL DESCRIPTION
Cardiovascular disease Familial hypercholesterolemia. Elevated LDL levels leading to coronary artery disease, xanthomas and corneal arcus. Hyperlipidemia Elevated low-density lipoproteins and triglycerides associated with premature coronary disease and peripheral vascular disease Alpha-1 antitrypsin deficiency 60–70% small airway and alveolar wall destruction, emphysema especially at bases, COPD Oncology conditions Multiple endocrine neoplasia (MEN 2a) (Familial medullary thyroid cancer) Medullary thyroid cancer, pheochromocytoma and parathyroid abnormalities Breast cancer BRCA1, BRCA2 hereditary breast/ovarian cancer Breast, ovarian, prostate and colon (BRCA1) Breast, ovarian and other cancer (BRCA2) Hereditary non-polyposis colorectal cancer Colorectal, endometrial, bladder, gastric, biliary and renal cell cancers as well as atypical endometrial hyperplasia and uterine leiomyosarcoma Li-Fraumeni syndrome Soft tissue sarcoma, breast cancer, leukemia, osteosarcoma, melanoma, and other cancers, often including colon, pancreas, adrenal cortex and brain Cowden syndrome Breast, non-medullary (papillary or follicular) thyroid cancer. Breast fibroadenomas and noncancerous thyroid nodules or goiter. Multiple buccal mucosa papillomas (cobblestone-line papules), facial trichilemmomas, gastrointestinal polyps. High arched palate, thickened furrowed tongue, megaloencephaly and pectus excavatum.
AGE OF ONSET
GENETIC INHERITANCE
TEST AVAILABILITY
40–50 years
A.D.
Research
30–40 years
Diagnostic and research
35 yr/smoker 45 yr/nonsmk
M.F. in A.R. fashion
Diagnostic and presymptomatic
Early adulthood
A.D.
Diagnostic and presymptomatic
30–70 years often –). The interneuronal fiber is an inhibitory neuron (−>–). When it is stimulated it, in turn, inhibits or shuts off transmission at the next junction. So a placebo has a (+) stimulatory effect on the descending control system, which has a stimulatory effect (+) on the interneuronal fiber, which has an inhibitory effect (−) on the ascending control system. A topical anesthetic has an inhibitory effect (−) on nerve transmission at the nociceptor level and a spinal anesthetic has the same impact (−) on the ascending nociceptive fibers.
Massage (+) Distraction (+) Placebo (+) Systemic opioids (+) Depression (–) Anxiety (+/–)
Descending control system
Ascending nociceptive fibers
Spinal local anesthetics (–) Epidural opioids (+) +
Topical anesthetics (–) Nonsteroidal anti-inflammatory agents (–) –
“Gate” or inhibitory interneuronal fiber
+ –
–
+
Nociceptor
Non-nociceptor Ice, heat, rubbing (+) Inflammation (–)
Excitatory effect Inhibitory effect
information is processed in the neuromatrix, a characteristic pattern emerges. This pattern, referred to as the neurosignature, is a continuous outflow from the neuromatrix. Ultimately, the neurosignature output, with a constant stream of input and varying patterns, produces the feelings of the whole body with constantly changing qualities. Melzack (1996) theorized that in the absence of modulating inputs from the missing limb, the active neuromatrix produces a neurosignature pattern that is perceived as pain. The neuromatrix theory highlights the role of the brain in sustaining the experience of pain. Some researchers have criticized this theory as not adding to the understanding of how psychological factors influence pain (Keefe, Lefebvre & Starr, 1996). While the neuromatrix theory might explain unusual pain phenomena, its contribution to understanding pain management remains to be seen.
FACTORS INFLUENCING THE PAIN RESPONSE A person’s pain experience is influenced by a number of factors, including past experiences with pain, anxiety, culture, age, gender, and expectations about pain relief. These factors may increase or decrease the person’s perception of pain, increase or decrease tolerance for pain, and affect the responses to pain.
Past Experience It is tempting to expect that a person who has had multiple or prolonged experiences with pain would be less anxious and more tolerant of pain than one who has had little pain. For most people, however, this is not true. Often, the more experience a person has had with pain, the more frightened he or she is about subsequent painful events. This person may be less able to tolerate pain; that is, he or she wants relief from pain sooner and before it becomes severe. This reaction is more likely to occur if the person has received inadequate pain relief in the past. A person with repeated pain experiences may have learned to fear the escalation of pain and its inadequate treatment. Once a person experiences severe pain, that person knows just how severe it can be. Conversely, someone who has never had severe pain may have no fear of such pain. The way a person responds to pain is a result of many separate painful events during a lifetime. For some, past pain may have been constant and unrelenting, as in prolonged or chronic and persistent pain. The individual who has pain for months or years may become irritable, withdrawn, and depressed. The undesirable effects that may result from previous experience point to the need for the nurse to be aware of the patient’s past experiences with pain. If pain is relieved promptly and adequately, the person may be less fearful of future pain and better able to tolerate it.
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Anxiety and Depression Although it is commonly believed that anxiety will increase pain, this is not necessarily true. Research has demonstrated no consistent relationship between anxiety and pain, nor has research shown that preoperative stress reduction training reduces postoperative pain (Keogh, Ellery, Hunt et al., 2001; Rhudy & Meagher, 2000). Postoperative anxiety is most related to preoperative anxiety and postoperative complications. However, anxiety that is relevant or related to the pain may increase the patient’s perception of pain. For example, a patient who was treated 2 years ago for breast cancer and now has hip pain may fear that the pain indicates metastasis. In this case, the anxiety may result in increased pain. Anxiety that is unrelated to the pain may distract the patient and may actually decrease the perception of pain. For example, a mother who is hospitalized with complications from abdominal surgery and is anxious about her children may perceive less pain as her anxiety about her children increases. The routine use of antianxiety medications to treat anxiety in someone with pain may prevent the person from reporting pain because of sedation and may impair the patient’s ability to take deep breaths, get out of bed, and cooperate with the treatment plan. The most effective way to relieve pain is by directing the treatment at the pain rather than at the anxiety. Just as anxiety is associated with pain because of concerns and fears about the underlying disease, depression is associated with chronic pain and unrelieved cancer pain. In chronic pain situations, depression is associated with major life changes due to the limiting effects of the pain, specifically unemployment. Longer durations of pain are associated with an increased incidence of depression (Wall, 1999). Unrelieved cancer pain drastically in-
terferes with the patient’s quality of life, and relieving the pain may go a long way toward treating the depression.
Culture Beliefs about pain and how to respond to it differ from one culture to the next. Early in childhood, individuals learn from those around them what responses to pain are acceptable or unacceptable. For example, a child may learn that a sports injury is not expected to hurt as much as a comparable injury caused by a motor vehicle crash. The child also learns what stimuli are expected to be painful and what behavioral responses are acceptable. These beliefs vary from one culture to another; therefore, people from different cultures who experience the same intensity of pain may not report it or respond to it in the same ways. Cultural factors must be taken into account to effectively manage pain. Many studies have examined the cultural aspects of pain. Inconsistent results, methodologic weaknesses or flaws (Lasch, 2000), and failure of many researchers to carefully distinguish ethnicity, culture, and race make it difficult to interpret the findings of many of these studies. Factors that help to explain differences in a cultural group include age, gender, education level, and income. In addition, the degree to which a patient identifies with a culture influences the degree to which he or she will adopt new health behaviors or cling to traditional health beliefs and practices. Other factors that affect a patient’s response to pain include his or her interaction with the health care system and provider factors (Lasch, Wilkes, Montuori et al., 2000). The nurse’s cultural values may differ from those of other cultures. The nurse’s cultural expectations and values may include avoiding exaggerated expressions of pain, such as excessive crying
NURSING RESEARCH PROFILE 13-1
Pain Management Outcomes for Hospitalized Hispanic Patients McNeill, J. A., Sherwood, G. D., Starck, P. L., & Nieto, B. (2001). Pain management outcomes for hospitalized Hispanic patients. Pain Management Nursing, 2(1), 25–36.
Purpose It has been suggested that members of minority groups are likely to receive inadequate pain management. Hispanics are the fastest-growing ethnic group in the United States, yet few studies have examined pain and its management in this group. The purposes of the study were to describe the experience of acute pain and pain management and outcomes of pain management, and to identify predictors of patient satisfaction in a minority sample. Study Sample and Design This cross-sectional, descriptive study explored the outcomes of the pain experience of hospitalized Hispanic patients and identified factors that contribute to patient satisfaction with pain management. The study sample consisted of 104 patients who were postoperative or diagnosed with a painful condition and who were hospitalized for at least 24 hours. The subjects identified themselves as Hispanic and spoke English. The researchers used the American Pain Society’s Patient Outcome Questionnaire–Modified and the Pain Management Index to measure the degree of pain, effectiveness of pain management, and patient satisfaction. Data related to analgesic orders and administration were obtained from the patients’ medical records. Findings Ninety-eight percent of the patients reported pain in the last 24 hours. The most interference caused by the pain was for participation in activities related to postoperative recovery (mean = 7.1, SD = 2.9) (on a 0–10 numeric scale with higher scores indicating more interference).
The least pain interference was in the area of interpersonal relationships (mean = 3.1, SD = 3.2). The mean score on satisfaction with pain management (on a 1–6 scale with higher scores indicating greater satisfaction) was 4.74 (SD = 1.2). Satisfaction with pain management was inversely and significantly correlated with pain intensity. The lower the patient’s pain score, the greater the satisfaction with management of pain. Only 66% of patients who reported pain received an analgesic within the previous 24 hours, although all patients had analgesics prescribed. The sample was divided into two groups: satisfied (n = 77) and dissatisfied (n = 23) with pain management. The dissatisfied patients reported higher pain now (p = 0.000), higher general pain in the last 24 hours (p = 0.000), and greater interference related to pain for activity (p = 0.000). Seventy-nine (77%) of the patients recalled receiving information about the importance of pain management. This factor did not influence satisfaction. Nursing Implications The findings in this study are similar to those noted in a sample of Caucasian patients. The satisfied and dissatisfied groups differed in the areas of pain rating now and general level of pain and interference related to pain regarding sleep, general activity, mood, and relationships. The reason for the reported high degree of satisfaction when those who reported pain and interference with activities is unclear. In spite of the inverse correlation between pain intensity and satisfaction, the satisfaction ratings were high. Further research is needed to identify the factors that determine satisfaction with pain management.
Chapter 13 and moaning, seeking immediate relief from pain, and giving complete descriptions of the pain. A patient’s cultural expectations may be to moan and complain about pain, to refuse pain relief measures that do not cure the cause of the pain, or to use adjectives such as “unbearable” in describing the pain. A patient from another cultural background may behave in a quiet, stoic manner rather than express the pain loudly. The nurse must react to the person’s pain perception and not to the pain behavior because the behavior is different from his or her own culture. Recognizing the values of one’s own culture and learning how these values differ from those of other cultures help to avoid evaluating the patient’s behavior on the basis of one’s own cultural expectations and values. A nurse who recognizes cultural differences will have a greater understanding of the patient’s pain and will be more accurate in assessing pain and behavioral responses to pain, as well as more effective in relieving the pain. The main issues to consider when caring for patients of a different culture are:
• What does the illness mean to the patient? • Are there culturally based stigmas related to this illness or • • • • • •
pain? What is the role of the family in health care decisions? Are traditional pain-relief remedies used? What is the role of stoicism in that culture? Are there culturally determined ways of expressing and communicating pain? Does the patient have any fears about the pain? Has the patient seen or does the patient want to see a traditional healer?
Regardless of the patient’s culture, nurses need to learn about that particular culture and be aware of power and communication issues that will affect care outcomes. Nurses need to avoid stereotyping patients by culture and provide individualized care rather than assuming that a patient of a specific culture will exhibit more or less pain. In addition to avoiding stereotyping, health care providers need to individualize the amount of medications or therapy according to the information provided by the patient. Nurses need to recognize that stereotypes exist and become sensitive to how stereotypes negatively affect care. Patients in turn must be instructed about how and what to communicate about their pain.
Age Age has long been the focus of research on pain perception and pain tolerance, and again the results have been inconsistent. For example, although some researchers have found that older adults require a higher intensity of noxious stimuli than do younger adults before they report pain (Washington, Gibson & Helme, 2000), others have found no differences in responses of younger and older adults (Edwards & Filligim, 2000). Other researchers have found that elderly patients (older than 65 years of age) reported significantly less pain than younger patients (Li, Greenwald, Gennis et al., 2001). Experts in the field of pain management have concluded that if pain perception is diminished in the elderly person, it is most likely secondary to a disease process (eg, diabetes) rather than to aging (American Geriatrics Society, 1998). More research is needed in the area of aging and its effects on pain perception to understand what the elderly are experiencing. Although many elderly people seek health care because of pain, others are reluctant to seek help even when in severe pain
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because they consider pain to be part of normal aging. Assessment of pain in older adults may be difficult because of the physiologic, psychosocial, and cognitive changes that often accompany aging. In one study, as many as 93% of nursing home residents reported being in pain daily for the past 6 months (Weiner, Peterson, Ladd et al., 1999). Unrelieved pain contributes to the problems of depression, sleep disturbances, delayed rehabilitation, malnutrition, and cognitive dysfunction (Miaskowski, 2000). The way an older person responds to pain may differ from the way a younger person responds. Because elderly people have a slower metabolism and a greater ratio of body fat to muscle mass than younger people, small doses of analgesic agents may be sufficient to relieve pain, and these doses may be effective longer (Buffum & Buffum, 2000). Elderly patients deal with pain according to their lifestyle, personality, and cultural background, as do younger adults. Many elderly people are fearful of addiction and, as a result, will not report that they are in pain or ask for pain medication. Others fail to seek care because they fear that the pain may indicate serious illness or they fear loss of independence. Elderly patients must receive adequate pain relief after surgery or trauma. When an elderly person becomes confused after surgery or trauma, the confusion is often attributed to medications, which are then discontinued. However, confusion in the elderly may be a result of untreated and unrelieved pain. In some cases postoperative confusion clears once the pain is relieved. Judgments about pain and the adequacy of treatment should be based on the patient’s report of pain and pain relief rather than on age.
Gender Researchers have studied gender differences in pain levels and in responses to pain. Once again, the results have been inconsistent. In one study, women tended to report higher levels of pain than men and reported their highest intensity of pain during the day, while men reported the highest intensity at night (Morin, Lund, Villarroel et al., 2000). Kelly (1998) reported no gender differences in pain. Riley, Robinson, Wade et al. (2001) compared pain intensity, pain unpleasantness, and pain-related emotions (depression, anxiety, frustration, fear, and anger) in men and women who were asked to rate their experiences with chronic pain. Women had higher pain intensity, pain unpleasantness, frustration, and fear compared to men. Robinson, Riley, Meyers et al. (2001) reported that men and women are socialized to respond differently and differ in their expectations relative to pain perception. In a study of responses of men and women to chronic pain and anxiety, Edwards, Auguston and Fillingim (2000) noted no difference between genders regarding pain and depression. There was, however, a difference in anxiety and gender, with men being more anxious about their pain. The pharmacokinetics and pharmacodynamics of opioids differ in men and women and have been attributed to hepatic metabolism, where the microsomal enzyme activity differs (Vallerand & Polomano, 2000). Genetic factors play a role in the varied responses to nonsteroidal anti-inflammatory drugs (NSAIDs) seen in men and women (Buffum & Buffum, 2000).
Placebo Effect A placebo effect occurs when a person responds to the medication or other treatment because of an expectation that the treatment will work rather than because it actually does so. Simply
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receiving a medication or treatment may produce positive effects. The placebo effect results from the natural (endogenous) production of endorphins in the descending control system. It is a true physiologic response that can be reversed by naloxone, an opioid antagonist (Wall, 1999). A patient’s positive expectations about treatment may increase the effectiveness of a medication or other intervention. Often the more cues the patient receives about the intervention’s effectiveness, the more effective it will be. A person who is informed that a medication is expected to relieve pain is more likely to experience pain relief than one who is told that a medication is unlikely to have any effect. Researchers have shown that different verbal instructions given to patients about therapies affect patient behavior and significantly reduce opioid intake. Pollo, Amanzio, Arslanina et al. (2001) studied the effect of information and expectations in patients who had undergone thoracotomy. Patients in three groups were given an intravenous infusion of normal saline solution and could receive a dose of buprenorphine (Buprenex) on request. One group was given no information about the analgesic effect of the regimen; one group was informed that the infusion received could be an analgesic or a placebo; the third was told that the infusion was a powerful analgesic. Although the three groups did not differ in reported level of pain, the group told that the infusion was a powerful analgesic used less opioid than the other two groups. A meta-analysis of 114 published research studies comparing placebo with no treatment showed similar results (Hrobjartsson & Gotzsche, 2001). The studies analyzed investigated many clinical conditions; 27 of the 114 trials involved the treatment of pain. Other clinical conditions in the studies included obesity, asthma, hypertension, insomnia, and anxiety. Pain was the only condition in which a placebo effect was demonstrated. The American Society of Pain Management Nurses (1996) holds the position that placebos (tablets or injections with no active ingredients) should not be used to assess or manage pain in any patient regardless of age or diagnosis. Furthermore, the group recommends that all health care institutions have policies in place prohibiting the use of placebos for this purpose. Educational programs should be conducted to educate providers about effective pain management, and ethics committees should assist in formulating these policies (Chart 13-2).
Nursing Assessment of Pain The highly subjective nature of pain makes pain assessment and management challenges for every clinician. The report of pain is a social transaction; thus, assessment and management of pain require a good rapport with the person in pain. In assessing a patient with pain, the nurse reviews the patient’s description of the pain and other factors that may influence pain (eg, previous experience, anxiety, and age) as well as the person’s response to pain relief strategies. Documentation of the pain level as rated on a pain scale becomes part of the patient’s medical record, as does a record of the pain relief obtained from interventions. Pain assessment includes determining what level of pain relief the acutely ill patient believes is needed to recover quickly or improve function, or what level of relief the chronically or terminally ill patient requires to maintain comfort (Chart 13-3). Part of a thorough pain assessment is to understand the patient’s expectations and misconceptions about pain (Chart 13-4). A person who understands that pain relief not only contributes to comfort but also hastens recovery is more likely to request or selfadminister treatment appropriately.
CHARACTERISTICS OF PAIN The factors to consider in a complete pain assessment are the intensity, timing, location, quality, personal meaning, aggravating and alleviating factors, and pain behaviors. The pain assessment begins by observing the patient carefully, noting the patient’s overall posture and presence or absence of overt pain behaviors and asking the person to describe, in his or her own words, the specifics of the pain. The words used to describe the pain may point toward the etiology. For example, the classic description of chest pain that results from a myocardial infarction includes pressure or squeezing on the chest. A detailed history should follow the initial description of pain.
Intensity The intensity of pain ranges from none to mild discomfort to excruciating. There is no correlation between reported intensity and the stimulus that produced it. The reported intensity is influenced by the person’s pain threshold and pain tolerance. Pain threshold is the smallest stimulus for which a person reports pain, and the tolerance is the maximum amount of pain a person can tolerate. To understand variations, the nurse can ask about the present pain intensity as well as the least and the worst pain intensity. Various tools and surveys are helpful to patients trying to describe pain intensity. Examples of pain scales appear in Figure 13-5.
Timing Sometimes the etiology of pain can be determined when time aspects are known. Therefore, the nurse inquires about the onset, duration, relationship between time and intensity, and whether there are changes in rhythmic patterns. The patient is asked if the pain began suddenly or increased gradually. Sudden pain that rapidly reaches maximum intensity is indicative of tissue rupture, and immediate intervention is necessary. Pain from ischemia gradually increases and becomes intense over a longer time. The chronic pain of arthritis illustrates the usefulness of determining the relationship between time and intensity, because people with arthritis usually report that pain is worse in the morning.
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Chart 13-3
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Pain at the End of Life
Pain is one of the most feared symptoms at the end of life. Most patients will experience pain as a terminal illness progresses. The inadequate treatment of cancer pain has been well documented (Agency for Health Care Policy and Research, 1994), and in the Study to Understand Prognoses and Preferences for Outcomes and Risks of Treatments (SUPPORT) (1995) investigators noted that nearly 40% of severely chronically ill and older patients who died in hospitals suffered moderate to severe pain in the last 3 days of life. The suffering caused by unrelieved pain touches all aspects of quality of life (activity, appetite, sleep) and can weaken an already fatigued person. Psychologically, unrelieved pain can create anxiety, and depression, negatively affect relationships, and promote thoughts of suicide. The Joint Commission on Accreditation of Health Care Organizations (JCAHO) implemented pain standards in January 2001. These standards present a unique opportunity to improve care for hospitalized patients. Even though hospices and palliative care agencies are not subject to JCAHO review, many patients with chronic illness who are receiving palliative care may be hospitalized at various times. The standards emphasize pain assessment, patient and family education, continuity of care for symptom management, and evaluation of interventions. Current barriers to pain management include lack of education, lack of access to opioids, fear of addiction, and legislative issues. Need for Education Ferrell et al. (2000) noted that of 45,683 nursing text pages reviewed, 902 were related to pain at the end of life. The end-of-life content constituted 2% of text pages, while the pain content represented only 0.5%. The researchers concluded that more specific content is needed to assist in educating students about pain and pain at the end of life. Accessibility The lack of access to opioids is another barrier to adequate pain relief. Patients may have difficulty affording medications. Some pharmacists, fearing crime, paperwork, and regulatory oversight, may not stock opioids or may keep limited quantities on hand. Some insurance companies limit the types of medications and the amount and frequency of renewal of analgesics. Addiction Fears The fear of addiction plays a role even at the end of life. Family members may be hesitant to assist the patient in pain management for fear of the social stigma of addiction. This causes needless pain and suffering. Legal Barriers Legislative issues play a role in the inadequate management of pain. Many states are enacting Intractable Pain Statutes. These laws aim to reduce physicians’ fear of civil or criminal liability or disciplinary action for aggressively managing pain. The tracking system by the Drug Enforcement Agency acts as a deterrent since opioids prescribed by
Location The location of pain is best determined by having the patient point to the area of the body involved. Some general assessment forms have drawings of human figures, and the patient is asked to shade in the area involved. This is especially helpful if the pain radiates (referred pain). The shaded figures are helpful in determining the effectiveness of treatment or change in the location of pain over time.
Quality The nurse asks the patient to describe the pain in his or her own words without offering clues. For example, the patient is asked
physicians can be tracked. Some physicians fear that prescribing “too many” opioids could be interpreted as treating an addicted patient. Other Issues Pain management at the end of life differs little from general pain management. Patients still require comprehensive pain assessment and pain management, even though assessment may be hampered by confusion, delirium, or unconsciousness. Caregivers are taught to observe for signs of restlessness or facial expressions as a “proxy” indicator of pain. Analgesic agents should be titrated to find the most effective dose and the best tolerated route. The nurse and family members should assess the effectiveness of the current pain therapy. If the pain is not relieved, a larger dose of medication may be necessary. If the pain continues, another medication may be needed or the patient should be given a different analgesic. The titration process requires frequent assessment to effectively manage pain. The analgesic agent or treatment should be appropriate for the type of pain. For example, neuropathic pain, usually described as burning, tingling, numbness, shooting, stabbing or electric, requires a different treatment approach compared to acute pain. Nonpharmacologic approaches, such as guided imagery and relaxation, can be used to decrease pain and help the patient cope. Careful patient positioning and environmental control are other methods to increase patient comfort. Respiratory depression should be assessed because over time, patients become tolerant to this side effect. The rate, depth, and level of consciousness should be monitored to determine whether respiratory depression is occurring and requires treatment. A respiratory rate of 6 per minute or greater is usually adequate. If respiratory depression is suspected, a decrease in the opioid dose may be indicated. Frequent stimulation to encourage deep breathing may be required until the opioid is metabolized. In the last few days of life the patient may become restless, which is an indicator of pain. The need to increase the opioid to provide pain relief and the respiratory effects of opioids are considered in decision making. However, comfort should be a priority in the case of a person who clearly is at the end of life, where cure is no longer the goal. Side effects from analgesics must be managed as in other painful conditions. Tolerance to constipation is rare. Thus, a careful bowel regimen involving diet, bowel stimulants, stool softeners, and/or osmotic agents, must be instituted. Vigilance in the assessment, management, and treatment evaluation of other side effects is similar to that included in previous discussions. Careful assessment and management of pain at the end of life can make a “good” death possible. Education of health care providers and the family can help patients realize the goal of adequate pain relief throughout the dying process.
to describe what the pain feels like. Sufficient time must be allowed for the patient to describe the pain and for the nurse to carefully record all words that are used. If the patient cannot describe the quality of the pain, words such as burning, aching, throbbing, or stabbing can be offered. It is important to document the exact words used to describe the pain and which words were suggested by the nurse conducting the assessment.
Personal Meaning Patients experience pain differently, and the pain experience can mean many different things. It is important to ask how the pain has affected the person’s daily life. Some people can continue to
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Chart 13-4
CONCEPTS AND CHALLENGES IN PATIENT MANAGEMENT Pain Intensity Scales
Common Concerns and Misconceptions About Pain and Analgesia
Simple Descriptive Pain Intensity Scale
• Complaining about pain will distract my doctor from his primary responsibility—curing my illness.
• Pain is a natural part of aging. • I don’t want to bother the nurse—he/she is busy with other • • • • • • •
patients. Pain medicine can’t really control pain. People get addicted to pain medicine easily. It is easier to put up with pain than with the side effects that come from pain medicine. Good patients avoid talking about pain. Pain medicine should be saved in case the pain gets worse. Pain builds character. It’s good for you. Patients should expect to have pain; it’s part of almost every hospitalization.
Adapted with permission from Gordon, D. B., & Ward, S. E. (1995). Correcting patient misconceptions about pain. American Journal of Nursing, 95(7).
work or study, while others may be disabled. The patient is asked if family finances have been affected. For others, the recurrence of pain may mean worsening of the disease, such as the spread of cancer. The meaning attached to the pain experience helps the nurse understand how the patient is affected and assists in planning treatment.
Aggravating and Alleviating Factors The nurse asks the patient what if anything makes the pain worse and what makes it better and asks specifically about the relationship between activity and pain. This helps detect factors associated with pain. For example, in a patient with advanced metastatic cancer, pain with coughing may signal spinal cord compression. The nurse ascertains whether environmental factors influence pain since they may easily be changed to help the patient. For example, making the room warmer may help the patient relax and may improve the patient’s pain. Finally, the patient is asked if pain is influenced by or affects the quality of sleep or anxiety. Both can significantly affect pain intensity and the quality of life. Knowledge of alleviating factors assists the nurse in developing a treatment plan. Therefore, it is important to ask about the patient’s use of medication (prescribed and over the counter) and the amount and frequency. In addition, the nurse asks if herbal remedies, nonpharmacologic interventions, or alternative therapies have been used with success. This information assists the nurse in determining teaching needs.
Pain Behaviors When experiencing pain, people express pain with many different behaviors. These nonverbal and behavioral expressions of pain are not consistent or reliable indicators of the quality or intensity of pain, and they should not be used to determine the presence of or the degree of pain experienced. Patients may grimace, cry, rub the affected area, guard the affected area, or immobilize it. Others may moan, groan, grunt, or sigh. Not all patients exhibit the same behaviors, and there may be different meanings associated with the same behavior.
Mild pain
No pain
Moderate pain
Severe pain
Very severe pain
Worst possible pain
0 – 10 Numeric Pain Intensity Scale
0 No pain
1
2
3
4
5 6 Moderate pain
7
8
9
10 Worst possible pain
Visual Analog Scale (VAS)
No pain
Pain as bad as it could possibly be
A 10-cm baseline is recommended for each of these scales.
FIGURE 13-5
Examples of pain intensity scales.
Sometimes in the nonverbal patient, pain behaviors are used as a proxy to assess pain. It is unwise to make judgments and formulate treatment plans based on behaviors that may or may not indicate pain. In the case of an unconscious person, pain should always be assumed to be present and treated. All patients have a right to adequate pain management. Physiologic responses to pain, such as tachycardia, hypertension, tachypnea, pallor, diaphoresis, mydriasis, hypervigilance, and increased muscle tone, are related to stimulation of the autonomic nervous system. These responses are short-lived as the body adapts to the stress. These physiologic signs could be the result of a change in the patient’s condition, such as the onset of hypovolemia. Using physiologic signs to indicate pain is unreliable. Although it is important to observe for any and all pain behaviors, the absence of these behaviors does not indicate an absence of pain.
INSTRUMENTS FOR ASSESSING THE PERCEPTION OF PAIN Only the patient can accurately describe and assess his or her pain. Clinicians consistently underestimate a patient’s level of pain (McCaffery & Ferrell, 1997; McCaffery, Ferrell & Pasaro, 2000; Puntillo, Miaskowski, Kehrle et al., 1997; Thomas et al., 1998). Therefore, a number of pain assessment instruments have been developed to assist in the assessment of a patient’s perception of pain (see Fig. 13-5). Such instruments may be used to document the need for intervention, to evaluate the effectiveness of the intervention, and to identify the need for alternative or additional interventions if the initial intervention is ineffective in relieving the pain. For a pain assessment instrument to be useful, it must require little effort on the part of the patient, be easy to understand and use, be easily scored, and be sensitive to small
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NURSING RESEARCH PROFILE 13-2
Pain Assessment and Titration of Analgesic Agents McCaffery, M., Ferrell, B. R., & Pasero, C. (2000). Nurses’ personal opinions about patients’ pain and their effect on recorded assessments and titration of opioid doses. Pain Management Nursing, 1(3), 79–87.
Purpose Nurses have a key role in pain assessment and management in all areas of clinical practice. Although previous studies have identified lack of knowledge about pain management as a factor contributing to undertreatment of pain, little is known about their personal opinions related to pain management. This study was conducted to explore how nurses’ personal opinions about pain intensity influence their decisions about pain assessment and about titration of the prescribed opioid to relieve severe pain. Study Sample and Design In this descriptive study, surveys were distributed as a pretest to a convenience sample of nurses attending pain conferences before receiving any information on pain. Data were collected at 20 locations throughout the United States. The surveys presented two vignettes describing patients with postoperative pain. The patients were identical except for their behavior; one patient was smiling and joking while the other remained quiet in bed and grimaced. Nurses were asked to identify their personal opinions about both patients’ reported pain intensity, what they would document in the patient record, and what opioid dose they would administer. Patients in both vignettes rated their pain as 8 on a scale of 0 to 10, indicating inadequate pain management and ineffective opioid doses to relieve the severe pain. In both vignettes, it was made clear that increasing the opioid dose would be safe and appropriate. Completed surveys were returned by 1,276 nurses. Of these, a random sample of 100 surveys from each section of the country was
changes in the characteristic being measured. Figure 13-6 shows a pain assessment algorithm that can be used at the time of assessment to direct clinical decisions for pain management.
Visual Analogue Scales Visual analogue scales (VAS; see Fig. 13-5) are useful in assessing the intensity of pain. One version of the scale includes a horizontal 10-cm line, with anchors (ends) indicating the extremes of pain. The person is asked to place a mark indicating where the current pain lies on the line. The left anchor usually represents “none” or “no pain,” whereas the right anchor usually represents “severe” or “worst possible pain.” To score the results, a ruler is placed along the line and the distance the person marked from the left or low end is measured and reported in millimeters or centimeters. Some patients (eg, children, elderly patients, and visually or cognitively impaired patients) may find it difficult to use an unmarked VAS. In those circumstances, ordinal scales (simple descriptive pain intensity scale, or 0 to 10 numeric pain intensity scale) may be used.
Faces Pain Scale, Revised This instrument has seven faces depicting expressions that range from contented to obvious distress. The patient is asked to point to the face that most closely resembles the pain intensity felt. Evidence for reliability and validity has been established (Hicks, van Baeyer, Spafford et al., 2001; Hunter, McDowell, Hennessy et al., 2000). Figure 13-7 shows the Faces Pain Scale, Revised.
obtained for a total of 400 surveys. Data from the 400 surveys were analyzed. Findings Although the nurses who completed the surveys indicated that they would record the patients’ pain as 8, fewer nurses believed the smiling patient than the grimacing patient. More nurses (78.3%) believed the grimacing patient’s pain intensity and 90% would have documented it correctly. A total of 39% of nurses reported believing the patient who was smiling, and 85.5% stated that they would have documented the reported pain intensity correctly. Nurses were also more likely to correctly increase the opioid dose for the grimacing patient; 62.5% of nurses indicated that they would have increased the dose for the grimacing patient, while only 47.3% reported that they would do so for the smiling patient. Of those nurses who would have increased the opioid dose for the grimacing patient, 16.3% would not do so for the smiling patient. Nursing Implications Comparing these results with those of previous studies conducted in 1990 and 1995, the authors noted considerable improvement in assessment and titration of opioids. However, the findings demonstrate that there is a continuing need for education about the different patient responses to pain and the importance of the patient’s report of the intensity of pain. More education is needed to address nurses’ responsibilities for opioid titration.
Guidelines for Using Pain Assessment Scales Using a written scale to assess pain may not be possible if the person is seriously ill, is in severe pain, or has just returned from surgery. In these cases, the nurse can ask the patient, “On a scale of 0 to 10, 0 being no pain and 10 being pain as bad as it can be, how bad is your pain now?” For patients who have difficulty with a 0 to 10 scale, a 0 to 5 scale may be tried. Whichever scale is used, it should be used consistently. Most patients usually can respond without difficulty. Ideally, the nurse teaches the patient how to use the pain scale before the pain occurs (eg, before surgery). The patient’s numerical rating is documented and used to assess the effectiveness of pain relief interventions. If the person does not speak English or cannot communicate clearly information needed to manage pain, an interpreter, translator, or family member familiar with the person’s method of communication should be consulted and a method established for pain assessment. Often a chart can be constructed with English words on one side and the foreign language on the other. The patient can then point to the corresponding word to tell the clinician about the pain. When a person with pain is cared for at home by family caregivers or the home care nurse, a pain scale may help in assessing the effectiveness of the interventions, if the scale is used before and after the interventions are administered. Scales that address the location and pattern of pain may be useful to the home care nurse in identifying new sources or sites of pain in the chronically or terminally ill patient and in monitoring changes in the patient’s level of pain. The patient and family caregivers can be taught to use a pain assessment scale to assess and manage the patient’s pain. The home care nurse who sees
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FIGURE 13-6
Pain assessment algorithm. Redrawn with permission from Salerno, E., & Willens, J. S. (1996). Pain management handbook: An interdisciplinary approach. St. Louis: C. V. Mosby.
the patient only at intervals may thus benefit from consulting the patient’s or family’s written record of the pain scores to evaluate how effective the pain management strategies have been over time. On occasion, a person will deny having pain when most people in similar circumstances would report significant pain. For example, it is not uncommon for a patient recovering from a total joint replacement to deny feeling “pain,” but on further questioning will readily admit to having a “terrible ache, but I wouldn’t call it pain.” From then on, when evaluating this person’s pain, the nurse would use the patient’s words rather than the word “pain.”
NURSE’S ROLE IN PAIN MANAGEMENT Before discussing what the nurse can do to intervene in the patient’s pain, the nurse’s role in pain management is reviewed. The nurse helps relieve pain by administering pain-relieving interventions (including both pharmacologic and nonpharmacologic approaches), assessing the effectiveness of those interventions, monitoring for adverse effects, and serving as an advocate for the patient when the prescribed intervention is ineffective in relieving pain. In addition, the nurse serves as an educator to the patient and family to enable them to manage the prescribed intervention themselves when appropriate.
FIGURE 13-7 Faces Pain Scale—Revised. This pain scale is especially suited for helping children describe pain. Instructions for using this scale follow: “These faces show how much something can hurt. This face (point to left-most face) shows no pain. The faces show more and more pain ( point to each from left to right) up to this one ( point to right-most face). It shows very much pain. Point to the face that shows how much you hurt (right now). Score the chosen face 0, 2, 4, 6 or 10, counting left to right, so 0 = no pain and 10 = very much pain. Do not use words like happy or sad. This scale is intended to measure how children feel inside, not how their face looks. From the Pediatric Pain Sourcebook. Original copyright © 2001. Used with permission of the International Association for the Study of Pain and the Pain Research Unit, Sydney Children’s Hospital, Randwick NSW 2031, Australia.
Chapter 13 Identifying Goals for Pain Management The information the nurse obtains from the pain assessment is used to identify goals for managing the pain. The goals identified are shared or validated with the patient. For a few patients, the goal may be elimination of the pain. For many, however, this expectation may be unrealistic. Other goals may include a decrease in the intensity, duration, or frequency of pain, and a decrease in the negative effects the pain has on the patient. For example, pain may have a negative effect by interfering with sleep and thereby hampering recovery from an acute illness or decreasing appetite. In such instances, the goals might be to sleep soundly and to take adequate nutrition. Chronic pain may affect the person’s quality of life by interfering with work or interpersonal relationships. Thus, a goal may be to decrease time lost from work or to increase the quality of interpersonal relationships. To determine the goal, a number of factors are considered. The first is the severity of the pain, as judged by the patient. The second factor is the anticipated harmful effects of pain. A highrisk patient is at much greater risk for the harmful effects of pain than a young healthy patient. The third factor is the anticipated duration of the pain. In patients with pain from a disease such as cancer, the pain may be prolonged, possibly for the remainder of the patient’s life. Therefore, interventions will be needed for some time and should not detract from the patient’s quality of life. A different set of interventions is required if the patient is likely to have pain for only a few days or weeks. In a study of the dying experience, family members of 2,451 people who had died were interviewed (Lynn, Teno, Phillips et al., 1997). Of these patients, 55% were conscious during their last 3 days of life. Of the conscious patients, 4 in 10 were considered by their family members to be in severe pain most of the time. These findings strongly suggest that pain relief for dying patients should be a primary goal. The goals for the patient may be accomplished by pharmacologic or nonpharmacologic means, but most success will be achieved with a combination of both. In the acute stages of illness, the patient may be unable to participate actively in relief measures, but when sufficient mental and physical energy is present, the patient may learn self-management techniques to relieve the pain. Thus, as the patient progresses through the stages of recovery, a goal may be to increase the patient’s use of selfmanagement pain relief measures.
Establishing the Nurse–Patient Relationship and Teaching A positive nurse–patient relationship and teaching are key to managing analgesia in the patient with pain, because open communication and patient cooperation are essential to success. A positive nurse–patient relationship characterized by trust is essential. By conveying to the patient the belief that he or she has pain, the nurse often helps reduce the patient’s anxiety. Acknowledging to the patient, “I know that you have pain” often eases the patient’s mind. Occasionally, patients who fear that no one believes the reported pain feel relieved when they know that the nurse can be trusted to believe the pain exists. Teaching is equally important, because the patient or family may be responsible for managing the pain at home and preventing or managing side effects. Teaching patients about pain and strategies to relieve it may reduce pain in the absence of other pain relief measures and may enhance the effectiveness of the pain relief measures used.
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The nurse also provides information by explaining how pain can be controlled. The patient is informed, for example, that pain should be reported in the early stages. When the patient waits too long to report pain, sensitization may occur and the pain may be so intense that it is difficult to relieve. The phenomenon of sensitization is important in effective pain management. Since a heightened response is seen after exposure to a noxious stimulus, the response to that stimulus will be greater, causing the person to feel more pain. When health care providers assess and treat pain before it becomes severe, sensitization is diminished or avoided, and thus less medication is needed.
Providing Physical Care The patient in pain may be unable to participate in the usual activities of daily living or to perform usual self-care and may need assistance to carry out these activities. The patient is usually more comfortable when physical and self-care needs have been met and efforts have been made to ensure as comfortable a position as possible. A fresh gown and change of bed linens, along with efforts to make the person feel refreshed (eg, brushing teeth, combing hair), often increase the level of comfort and improve the effectiveness of the pain relief measures. Providing physical care to the patient also gives the nurse (in acute, long-term, and home settings) the opportunity to perform a complete assessment and to identify problems that may contribute to the patient’s discomfort and pain. Appropriate and gentle physical touch during care may be reassuring and comforting. If topical treatments such as fentanyl (an opioid analgesic) patches or intravenous or intraspinal catheters are used, the skin around the patch or catheter should be assessed for integrity during physical care.
Managing Anxiety Related to Pain Anxiety may affect a patient’s response to pain. The patient who anticipates pain may become increasingly anxious. Teaching the patient about the nature of the impending painful experience and the ways to reduce pain often decreases anxiety; a person who is experiencing pain will use previously learned strategies to reduce anxiety and pain. Learning about measures to relieve pain may lessen the threat of pain and give the person a sense of control. What the nurse explains about the available pain relief measures and their effectiveness may also affect the patient’s anxiety level. The patient’s anxiety may be reduced by explanations that point out the degree of pain relief that can be expected from each measure. For example, the patient who is informed beforehand that an intervention may not eliminate pain completely is less likely to become anxious when a certain amount of pain persists. Anxiety resulting from anticipation of pain or the pain experience itself may often be managed effectively by establishing a relationship with the patient and by patient teaching. A patient who is anxious about pain may be less tolerant of the pain, which in turn may increase the anxiety level. To prevent the pain and anxiety from escalating, the anxiety-producing cycle must be interrupted. Low levels of pain are easier to reduce or control than are more intense levels. (This concept of sensitization was previously discussed.) Consequently, pain relief measures should be used before pain becomes severe. Many patients believe that they should not request pain relief measures until they cannot tolerate the pain, making it difficult for medications to provide relief. Therefore, it is important to explain to all patients that pain relief or control is more successful if such measures begin before the pain becomes unbearable.
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Pain Management Strategies Reducing pain to a “tolerable” level was once considered the goal of pain management. However, even patients who have described pain relief as adequate often report disturbed sleep and marked distress because of pain. In view of the harmful effects of pain and inadequate pain management, the goal of tolerable pain has been replaced by the goal of relieving the pain. Pain management strategies include both pharmacologic and nonpharmacologic approaches. These approaches are selected on the basis of the patient’s requirements and goals. Appropriate analgesic medications are used as prescribed. They are not considered a last resort to be used only when other pain relief measures fail. Any intervention is most successful if initiated before pain sensitization occurs, and the greatest success is usually achieved if several interventions are applied simultaneously.
PHARMACOLOGIC INTERVENTIONS Managing a patient’s pain pharmacologically is accomplished in collaboration with the physician or other primary care provider, the patient, and often the family. The physician or nurse practitioner prescribes specific medications for pain or may insert an intravenous line for administering analgesic medications. Alternatively, an anesthesiologist or nurse anesthetist may insert an epidural catheter for their administration. However, it is the nurse who maintains the analgesia, assesses its effectiveness, and reports if the intervention is ineffective or produces side effects. The pharmacologic management of pain requires close collaboration and effective communication among health care providers. In the home setting, it is often the family who manages the patient’s pain and assesses the effectiveness of pharmacologic interventions, while it is the home care nurse who evaluates the adequacy of pain relief strategies and the family’s ability to manage the pain. The home care nurse reinforces teaching and ensures communication among the patient, family care providers, physician, pharmacist, and other health care providers involved in the patient’s care.
Premedication Assessment Before administering any medication, the nurse asks the patient about allergies to medications and the nature of any previous allergic responses. True allergic or anaphylactic responses to opioids are rare, but it is not uncommon for a patient to report an allergy to one of the opioids. On further examination, the nurse often learns that the extent of the allergy was “itching” or “nausea and vomiting.” These responses are not allergies; rather, they are side effects that, when necessary, can be managed while the patient’s pain is relieved. The patient’s description of responses or reactions should be documented and reported before administering the medication. The nurse obtains the patient’s medication history (eg, current, usual, or recent use of prescription or over-the-counter medications or herbal agents), along with a history of health problems. Certain medications or conditions may affect the analgesic medication’s effectiveness or the metabolism and excretion of analgesic agents. Before administering analgesic agents, the nurse should assess the patient’s pain status, including the intensity of current pain, changes in pain intensity after the previous dose of medication, and side effects of the medication.
Approaches for Using Analgesic Agents Medications are most effective when the dose and interval between doses are individualized to meet the patient’s needs. The only safe and effective way to administer analgesic medications is by asking the patient to rate the pain and by observing the response to medications. BALANCED ANESTHESIA Pharmacologic interventions are most effective when a multimodal or balanced analgesia approach is used. Balanced analgesia refers to use of more than one form of analgesia concurrently to obtain more pain relief with fewer side effects. Three general categories of analgesic agents are opioids, NSAIDs, and local anesthetics. These agents work by different mechanisms. Using two or three types of agents simultaneously can maximize pain relief while minimizing the potentially toxic effects of any one agent. When one agent is used alone, it usually must be used in a higher dose to be effective. In other words, although it might require 15 mg morphine to relieve a certain pain, it may take only 8 mg morphine plus 30 mg ketorolac (an NSAID) to relieve the same pain. PRO RE NATA (PRN) In the past, the standard method used by most nurses and physicians in administering analgesia was to administer the analgesic pro re nata (PRN), or “as needed.” The standard practice was for the nurse to wait for the patient to complain of pain and then administer analgesia. As a result, many patients remained in pain because they did not know they needed to ask for medication or waited until the pain became intolerable. By its very nature, the PRN approach to analgesia leaves the patient sedated or in severe pain much of the time. To receive pain relief from an opioid analgesic, the serum level of that opioid must be maintained at a minimum therapeutic level (Fig. 13-8). By the time the patient complains of pain, the serum opioid level is below the therapeutic level. From the time the patient requests pain medication until the nurse administers the medication, the patient’s serum level continues to fall. The lower the serum opioid level, the more difficult it is to achieve the therapeutic level with the next dose. The only way to ensure significant periods of analgesia, using this method, is to give doses large enough to produce periods of sedation. PREVENTIVE APPROACH Currently, a preventive approach to relieving pain by administering analgesic agents is considered the most effective strategy because a therapeutic serum level of medication is maintained. With the preventive approach, analgesic agents are administered at set intervals so that the medication acts before the pain becomes severe and before the serum opioid level falls to a subtherapeutic level. Administering analgesic medication on a time basis, rather than on the basis of the patient’s report of pain, prevents the serum drug level from falling to subtherapeutic levels. An example of this would be giving the patient the prescribed morphine or the prescribed NSAID (ibuprofen) every 4 hours rather than waiting until the patient complains of pain. If the patient’s pain is likely to occur around the clock or for a great portion of a 24-hour period, a regular around-the-clock schedule of administering analgesia may be indicated. Even if the analgesic is prescribed PRN, it can be administered on a preventive basis before the pa-
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Respiratory depression Sedation IM
Analgesia PCA
minimum therapeutic level
Pain Hours 0
1
2
3
4
5
6
7
8
9
10
11
12
13
14
Respiratory depression Sedation Analgesia minimum therapeutic level
FIGURE 13-8
Relationship of mode of delivery of analgesia to serum analgesic level. Top: intramuscular (IM) and intravenous patient-controlled analgesia (PCA); bottom: transdermal (TD) and transmucosal (•).
TD
Pain Hours 0
5
10
15
20
25
30
35
40
45
50
55
60
65
70
80
TD = Transdermal = Transmucosal
tient is in severe pain, as long as the prescribed interval between doses is observed. The preventive approach reduces the peaks and troughs in the serum level and provides more pain relief for the patient with fewer adverse effects. Smaller doses of medication are needed with the preventive approach because the pain does not escalate to a level of severe intensity. Thus, a preventive approach may result in the administration of less medication over a 24-hour period, thereby helping prevent tolerance to analgesic agents and decreasing the severity of side effects (eg, sedation and constipation). Better pain control can be achieved with a preventive approach, reducing the amount of time the patient spends in pain. In using the preventive approach, the nurse assesses the patient for sedation before administering the next dose. The goal is to provide analgesia before the pain becomes severe. It would not be safe to medicate a patient (with an opioid) repeatedly if he or she was sedated or having no pain. It may be necessary to decrease the dosage of the opioid analgesic so that the patient receives pain relief with less sedation.
with an extremely low incidence (less than 1%) of addiction. Furthermore, small doses are not necessarily safe doses. For example, some patients receiving a relatively small dose (25 to 50 mg) of meperidine (Demerol) intramuscularly have experienced respiratory depression, whereas other patients have not exhibited any sedation or respiratory depression with very large doses of opioids.
INDIVIDUALIZED DOSAGE The dosage and the interval between doses should be based on the patient’s requirements rather than on an inflexible standard or routine. People metabolize and absorb medications at different rates and experience different levels of pain. Therefore, one dose of an opioid medication given at specified intervals may be effective for one patient but ineffective for another. Because of the fear of promoting addiction or causing respiratory depression, health care providers tend to prescribe and administer inadequate dosages of opioid agents to treat acute pain or chronic pain in the terminally ill patient (Chart 13-5). However, even prolonged administration of opioid agents is associated
Dilemma Racial biases are difficult to change and deal with. To confront this nurse may not alter the behavior but will certainly disrupt the working relationships on the unit. It would be easier to look the other way. On the other hand, you believe that the nurse is giving inadequate and unethical care to selected patients and placing them at greater risk for postoperative complications.
Chart 13-5
• Ethics and Related Issues
Inadequate Pain Management Situation When taking over the care of ethnic minority patients at the change of shift from a particular colleague, you usually find these patients to be in a great deal of pain. Your nonsystematic observations have led you to conclude these patients receive only a small portion of the analgesia prescribed for them. You have heard a nurse colleague state a belief that people of certain ethnic groups have “no pain tolerance” and are “just looking for drugs.”
Discussion • What information would you need to collect before acting? • From whom could you seek counsel? • Are the two aspects of the dilemma equally important?
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Therefore, the effects of opioid analgesic medications must be monitored, especially when the first dose is given or when the dose is changed or given more frequently. The time, date, the patient’s pain rating (scale of 0 to 10), the analgesic agent, other pain relief measures, side effects, and patient activity are recorded. When the first dose of an analgesic is administered, the nurse needs to record a pain rating score, blood pressure, and respiratory and pulse rates (all of which are considered “vital signs”). If the pain has not decreased in 30 minutes (sooner if an intravenous route is used) and the patient is reasonably alert and has a satisfactory respiratory status, blood pressure, and pulse rate, then some change in analgesia is indicated. Although the dose of analgesic medication is safe for this patient, it is ineffective in relieving the pain. Therefore, another dose of medication may be indicated. In such instances, the nurse consults with the physician to determine what further action is warranted. PATIENT-CONTROLLED ANALGESIA Used to manage postoperative pain as well as chronic pain, patientcontrolled analgesia (PCA) allows patients to control the administration of their own medication within predetermined safety limits. This approach can be used with oral analgesic agents as well as with continuous infusions of opioid analgesic agents by intravenous, subcutaneous, or epidural routes. PCA can be used in the hospital or home setting. The PCA pump permits the patient to self-administer continuous infusions of medication (basal rates) safely and to administer extra medication (bolus doses) with episodes of increased pain or painful activities. A PCA pump is electronically controlled by a timing device. Patients experiencing pain can administer small amounts of medication directly into their intravenous, subcutaneous, or epidural catheter by pressing a button. The pump then delivers a preset amount of medication. The PCA pump also can be programmed to deliver a constant, background infusion of medication or basal rate and still allow the patient to administer additional bolus doses as needed. The timer can be programmed to prevent additional doses from being administered until a specified time period has elapsed (lock-out time) and until the first dose has had time to exert its maximal effect. Even if the patient pushes the button multiple times in rapid succession, no additional doses are released. If another dose is required at the end of the delay period, the button must be pushed again to receive the dose. Patients who are controlling their own opioid administration usually become sedated and stop pushing the button before any significant respiratory depression occurs. Nevertheless, assessing respiratory status remains a major role for the nurse. A continuous infusion plus bolus doses may be effective with cancer patients who require large doses of analgesia, or for postsurgical patients. Although this allows more uninterrupted sleep, the risk of sedation increases, especially when the patient has minimal or decreasing pain. Patients who use PCA achieve better pain relief (Walder, Schafer, Henzi et al., 2001) and often require less pain medication than those who are treated in the standard PRN fashion. Because the patient can maintain a near-constant level of medication, the periods of severe pain and sedation that occur with the traditional PRN regimen are avoided. To initiate PCA or any analgesia used at home or in the hospital, it is important to avoid playing “catch-up.” Pain should be brought under control before PCA starts, often by the use of an initial, larger bolus dose or loading dose. Then, after control is achieved, the pump is programmed to deliver small doses of med-
ication at a time. If the patient with severe pain has a low serum level of opioid analgesic because of an inadequate basal rate, it is difficult to regain control with the small doses available by pump. Before the PCA pump is used, repeated bolus doses of an intravenous opioid may be administered as prescribed over a short time until the pain is relieved. Then PCA is initiated. If pain control is not achieved with the maximal dose of medication prescribed, further prescriptions are obtained. The goal is to achieve a minimum therapeutic level of analgesia and to allow the patient to maintain that level by using the PCA pump. The patient is instructed not to wait until the pain is severe before pushing the button to obtain a bolus dose. The patient is also reminded not to become so distracted by an activity or visitor that he or she forgets to self-administer a prescribed dose of medication. One potential drawback to distraction is that a patient who is using a PCA pump may not self-administer any analgesia during the time of effective distraction. When distraction ends suddenly (eg, the movie ends or the visitors leave), the patient may be left without a therapeutic serum opioid level. When intermittent distraction is used for pain relief, a continuous low-level background infusion of opioid through the PCA pump may be prescribed so that when the distraction ends, it will not be necessary to try to catch up. If PCA is to be used in the patient’s home, the patient and family are taught about the operation of the pump and the side effects of the medication and strategies to manage them.
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NURSING ALERT Family members are cautioned not to push the button for the patient, especially if the patient is asleep, because this overrides some of the safety features of the system.
Local Anesthetic Agents Local anesthetics work by blocking nerve conduction when applied directly to the nerve fibers. They can be applied directly to the site of injury (eg, a topical anesthetic spray for sunburn) or directly to nerve fibers by injection or at the time of surgery. They can also be administered through an epidural catheter. TOPICAL APPLICATION Local anesthetic agents have been successful in reducing the pain associated with thoracic or upper abdominal surgery when injected by the surgeon intercostally. Local anesthetic agents are rapidly absorbed into the bloodstream, resulting in decreased availability at the surgical or injury site and an increased anesthetic level in the blood, increasing the risk of toxicity. Therefore, a vasoconstrictive agent (eg, epinephrine or phenylephrine) is added to the anesthetic agent to decrease its systemic absorption and to maintain its concentration at the surgical or injury site. A topical anesthetic agent known as eutectic mixture or emulsion of local anesthetics, or EMLA cream, has been effective in preventing the pain associated with invasive procedures such as lumbar puncture or the insertion of intravenous lines. To be effective, EMLA must be applied to the site 60 to 90 minutes before the procedure. INTRASPINAL ADMINISTRATION Intermittent or continuous administration of local anesthetic agents through an epidural catheter has been used for years to produce anesthesia during surgery. Although the administration of local anesthetic agents in the spinal canal is still largely confined to acute pain, such as postoperative pain and pain associated with labor and delivery, the epidural administration of local anesthetic agents for pain management is increasing.
Chapter 13 A local anesthetic agent administered through an epidural catheter is applied directly to the nerve root. The anesthetic agent can be administered continuously in low doses, intermittently on a schedule, or on demand as the patient requires it, and is often combined with the epidural administration of opioids. Surgical patients treated with this combination experience fewer complications after surgery, ambulate sooner, and have shorter hospital stays than patients receiving standard therapy (Correll, Viscusi, Grunwald et al., 2001).
Opioid Analgesic Agents Opioids can be administered by various routes, including oral, intravenous, subcutaneous, intraspinal, intranasal, rectal, and transdermal routes. The goal of administering opioids is to relieve pain and improve quality of life; therefore, the route of administration, dose, and frequency of administration are determined on an individual basis. Factors that are considered in determining the route, dose, and frequency of medication include the characteristics of the pain (eg, its expected duration and severity), the overall status of the patient, the patient’s response to analgesic medications, and the patient’s report of pain. Although the oral route is usually preferred for administering opioids, oral opioids must be given frequently enough and in large enough doses to be effective. Opioid analgesic agents given orally may provide a more consistent serum level than those given intramuscularly. If the patient is expected to require opioid analgesic agents at home, the patient’s and the family’s ability to administer opioids as prescribed is considered in planning. Steps are taken to ensure that the medication will be available to the patient. Many pharmacies, especially those in smaller rural areas or inner cities, may be reluctant to stock large amounts of opioids. Therefore, arrangements for obtaining these prescription medications must be made ahead of time. With the administration of opioids by any route, side effects must be considered and anticipated. Anticipating side effects and taking steps to minimize them increase the likelihood that the patient will receive adequate pain relief without interrupting therapy to treat these effects. RESPIRATORY DEPRESSION AND SEDATION Respiratory depression is the most serious adverse effect of opioid analgesic agents administered by intravenous, subcutaneous, or epidural routes. However, it is relatively rare because doses administered through these routes are small, and tolerance to respiratory depressant effects increases if the dose is increased slowly. The risk of respiratory depression increases with age and the concomitant use of other opioids or other central nervous system depressants. The risk of respiratory depression also increases when the catheter is placed in the thoracic area and when the intraabdominal or intrathoracic pressure is increased. The patient receiving opioids by any route must be assessed frequently for changes in respiratory status. Specific notable changes are decreasing respiratory rate or shallow respirations. Despite the risks associated with their use, intravenous and epidural opioids are considered safe, with the risks related to epidural administration no greater than those related to intravenous or other systemic routes of administration. Sedation, which may occur with any method of administering opioids, is likely to occur when opioid doses are increased. However, the patient often develops tolerance quickly, so that in a short time the patient is no longer sedated by the dose that initially caused sedation. Increasing the time between doses or reducing the dose temporarily, as prescribed, usually pre-
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vents deep sedation from occurring. The patient at risk for sedation must be monitored closely for changes in respiratory status. The patient is also at risk for other problems associated with sedation and immobility. Therefore, the nurse must initiate strategies to prevent problems such as skin breakdown. NAUSEA AND VOMITING Nausea and vomiting frequently occur with opioid use. Usually these effects occur some hours after the initial injection. Patients, especially postoperative patients, may not think to tell the nurse that they are nauseated, particularly if the nausea is mild. However, the patient receiving an opioid should be assessed for nausea and vomiting, which may be triggered by a position change and may be prevented by having the patient change positions slowly. Adequate hydration and the administration of antiemetic agents may decrease the incidence. Opioid-induced nausea and vomiting often subside within a few days. CONSTIPATION Constipation, a common side effect of opioid use, may become so severe that the patient is forced to choose between relief of pain and relief of constipation. This situation can occur in patients after surgery and in patients receiving large doses of opioids to treat cancer-related pain. Preventing constipation must be a high priority in all patients receiving opioids. Whenever a patient receives opioids, a bowel regimen should begin at the same time. Tolerance to this side effect does not occur; rather, it persists even with long-term use of opioids. Several strategies may help prevent and treat opioid-related constipation. Mild laxatives and a high intake of fluid and fiber may be effective in managing mild constipation. Unless contraindicated, a mild laxative and a stool softener should be administered on a regular schedule. Continued severe constipation, however, often requires the use of a stimulating cathartic agent, such as senna derivatives (Senokot) or bisacodyl (Dulcolax). Oral laxatives and stool softeners may prevent constipation; rectal suppositories may be used if oral agents fail (Plaisance & Ellis, 2002). INADEQUATE PAIN RELIEF One factor commonly associated with ineffective pain relief is an inadequate dose of opioid. This is most likely to occur when the caregiver underestimates the patient’s pain or the route of administration is changed without the differences in absorption and action being considered. Consequently, the patient receives doses too small to be effective and, possibly, too infrequently to relieve pain. For example, if opioid delivery is changed from the intravenous route to the oral route, the oral dose must be approximately three times greater than that given parenterally to provide relief. Because of differences in absorption of orally administered opioids among individuals, the patient must be assessed carefully to ensure that the pain is relieved. Table 13-2 lists opioids and dosages that are equivalent to morphine. In general, no recalculation needs to be done when switching from one brand of an agent to another brand of the same medication, with the exception of extended-release oral morphine. Currently, three brands of extended-release morphine (MS Contin, Oramorph, Kadian) are commonly used by cancer patients. Although these agents come in the same dosage form and contain the same drug, they are not considered therapeutically equivalent because they employ different release mechanisms. Patients who need to switch brands should be monitored carefully both for overdose and for inadequate pain relief.
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Table 13-2
• Equianalgesic Conversion Table ADMINISTRATION ROUTE
Half-life (in hours)
Duration (in hours)
IV/IM/SQ
Morphine sulfate Codeine Hydromorphone Levorphanol Meperidine Methadone Oxycodone Oxymorphone
10 mg 30 mg 1⬊3 2 to 3 2 to 4 130 mg 200 mg NA 2 to 3 2 to 4 1.5 mg 7.5 mg 1:5 2 to 3 2 to 4 2 mg 4 mg 1:2 12 to 15 4 to 6 75 mg 300 mg 1⬊4 3 to 4 2 to 4 10 mg 20 mg 1⬊2 12 to 190 4 to 8 NA 20 to 30 mg NA 2 to 3 2 to 4 1 mg or NA NA 2 to 3 2 to 4 10-mg suppository 100-mcg patch = 4 mg/hr v morphine sulphate based on anecdotal experience
Fentanyl (transdermal)
PO
IV:PO Ratio
Drug
NA = not applicable. Derby, S. A. (1999). Opioid conversion guidelines for managing adult cancer pain. American Journal of Nursing, 99(10), 62–65.
OTHER EFFECTS OF OPIOIDS During the health history, when asked about drug allergies, patients with previous hospital experience (especially for surgery) may report that they are “allergic” to morphine. This report should be thoroughly investigated. Commonly, this “allergy” will be described as itching only. Pruritus (itching) is a frequent problem associated with opioids administered through any route, but it is not an allergic reaction. Itching can be relieved by administering prescribed antihistamines. Epidurally administered opioids may also cause urinary retention or pruritus. The patient should be monitored and may require urinary catheterization. Small doses of naloxone may be prescribed to relieve these problems in patients who are receiving epidural opioids for the relief of acute postoperative pain. A number of factors may influence the safety and effectiveness of opioid administration. Opioid analgesic agents are primarily metabolized by the liver and excreted by the kidney. Therefore, metabolism and excretion of analgesic medications will be impaired in patients with liver or kidney disease, increasing the risk of cumulative or toxic effects. In addition, normeperidine, a metabolite of meperidine, may rapidly or unexpectedly accumulate to toxic levels. This is more likely to occur in patients with impaired kidney function and may result in seizures in susceptible patients. Patients with untreated hypothyroidism are more susceptible to the analgesic effects and side effects of opioids. In contrast, patients with hyperthyroidism may require larger doses for pain relief. Patients with a decreased respiratory reserve from disease or aging may be more susceptible to the depressant effects of opioids and must be carefully monitored for respiratory depression. Dehydrated patients are at increased risk for the hypotensive effects of opioids. Patients who become hypotensive after the administration of an opioid should be kept recumbent and rehydrated unless fluids are contraindicated. Patients who are dehydrated are also more likely to experience nausea and vomiting with opioid use. Rehydration usually relieves these symptoms. Patients receiving certain other medications, such as monoamine oxidase (MAO) inhibitors, phenothiazines, or tricyclic antidepressants, may have an exaggerated response to the depressant effects of opioids. Patients taking these medications should receive small doses of opioids and must be monitored closely. Continued pain in these patients indicates that a therapeutic level of the analgesic has not been achieved. The patient
must be monitored for sedation even if an analgesic effect has not been obtained. TOLERANCE AND ADDICTION There is no maximum safe dosage of opioids, nor is there any easily identifiable therapeutic serum level. Both the maximal safe dosage and therapeutic serum level are relative and individual. Tolerance (the need for increasing doses of opioids to achieve the same therapeutic effect) will develop in almost all patients taking opioids over an extended period. Patients requiring opioids over a long term, especially cancer patients, will need increasing doses to relieve pain. After the first few weeks of therapy, the patient’s dosing requirements usually level off. Patients who become tolerant to the analgesic effects of large doses of morphine may obtain pain relief by switching to a different opioid. Symptoms of physical dependence may occur when the opioids are discontinued; dependence often occurs with opioid tolerance and does not indicate an addiction.
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NURSING ALERT Although patients may need increasing levels of opioids, they are not addicted. Physical tolerance usually occurs in the absence of addiction. Tolerance to opioids is common and becomes a problem primarily in terms of delivering or administering the medication (eg, how to administer very large doses of morphine a day to a patient). On the other hand, addiction is rare and should never be the primary concern of the nurse caring for a patient in pain.
Addiction is a behavioral pattern of substance use characterized by a compulsion to take the drug primarily to experience its psychic effects. Fear that patients will become addicted or dependent on opioids has contributed to inadequate treatment of pain. This fear is commonly expressed by health care providers as well as patients and results from lack of knowledge about the low risk of addiction. In an often-cited classic study (Porter & Jick, 1980) of more than 11,000 patients receiving opioids for a medical indication, only four patients without a history of substance abuse could be identified as becoming addicted. Addiction following therapeutic opioid administration is so negligible that it should not be a consideration when caring for the patient in pain. Thus, patients and health care providers should be dissuaded from withholding pain medication because of concerns about addiction.
Chapter 13 Nonsteroidal Anti-inflammatory Drugs NSAIDs are thought to decrease pain by inhibiting cyclo-oxygenase (COX), the rate-limiting enzyme involved in the production of prostaglandin from traumatized or inflamed tissues. There are two types of COX: COX-1 and COX-2. COX-1 is involved with mediating prostaglandin formation involved in the maintenance of physiologic functions. Some of the physiologic functions include platelet aggregation through the provision of thromboxane precursors and increased gastric mucosal blood flow. This prevents ischemia and promotes mucosal integrity. Inhibition of COX-1 will result in gastric ulceration, bleeding, and renal damage. The second type, COX-2, mediates prostaglandin formation that results in symptoms of pain, inflammation, and fever. Thus, inhibition of COX-2 is desirable. Newer NSAIDs such as celecoxib (Celebrex), rofecoxib (Vioxx), and valdecoxib (Bextra) are COX-2 inhibitors. Ibuprofen (Advil, Motrin), another NSAID, blocks both COX-1 and COX-2 and is effective in relieving mild to moderate pain and has a low incidence of adverse effects. Aspirin, the oldest NSAID, also blocks COX-1 as well as COX-2; however, because it causes frequent and severe side effects, aspirin is infrequently used to treat significant acute or chronic pain. NSAIDs are very helpful in treating arthritic diseases and may be especially powerful in treating cancer-related bone pain. They have been effectively combined with opioids to treat postoperative and other severe pain. The use of an NSAID with an opioid relieves pain more effectively than the opioid alone. In such cases, the patient may obtain pain relief with less opioid and fewer side effects. It has been shown that intraoperative administration of NSAIDs results in improved postoperative pain control following laparoscopic surgery and in some cases shorter hospital stays (McLaughlin, 1994). A regimen of a fixed-dose, time-contingent NSAID (eg, every 4 hours) and a separately administered fluctuating dose of opioid may be effective in managing moderate to severe cancer pain. In more severe pain, the opioid dose will also be fixed, with an additional fluctuating dose as needed for breakthrough pain (a sudden increase in pain despite the administration of pain-relieving medications). These regimens result in better pain relief with fewer opioid-related side effects. Most patients tolerate NSAIDs well. However, those with impaired kidney function may require a smaller dose and must be monitored closely for side effects. Patients taking NSAIDs bruise easily because NSAIDs have some anticoagulant effect. Moreover, they may displace other medications, such as warfarin (Coumadin), from serum proteins and increase their effects. High doses or prolonged use can irritate the stomach and in some cases result in gastrointestinal bleeding as well. Thus, monitoring the patient for gastrointestinal bleeding is indicated. Gerontologic Considerations Related to Analgesic Agents Physiologic changes in older adults require that analgesic agents be administered with caution. Drug interactions are more likely to occur in older adults because of the higher incidence of chronic illness and the increased use of prescription and over-the-counter medications. Although the elderly population is an extremely heterogeneous group, differences in response to pain or medications by a patient in this 40-year span (60 to 100 years) are more likely to be due to chronic illness or other individual factors than age. Before administering opioid and nonopioid analgesic agents to elderly patients, the nurse needs to obtain a careful medication history to identify potential drug interactions.
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Absorption and metabolism of medications are altered in elderly patients because of decreased liver, renal, and gastrointestinal function. In addition, changes in body weight, protein stores, and distribution of body fluid alter the distribution of medications in the body. As a result, medications are not metabolized as quickly and blood levels of the medication remain higher for a longer period. Elderly patients are more sensitive to medications and at an increased risk for drug toxicity (American Geriatrics Society, 1998). Opioid and nonopioid analgesic medications can be given effectively to elderly patients but must be used cautiously because of the increased susceptibility to depression of both the nervous and the respiratory systems. Although there is no reason to avoid opioids simply because a person is elderly, meperidine should be avoided because its active and neurotoxic metabolite, normeperidine, is more likely to accumulate in the elderly. In addition, because of decreased binding of meperidine by plasma proteins, blood concentrations of the medication twice those found in younger patients may result. In many cases, the initial dose of analgesic medication prescribed for an elderly patient may be the same as that for a younger person, or slightly smaller than the normal dose, but because of slowed metabolism and excretion related to aging, the safe interval for subsequent doses may be longer (or prolonged). As always, the best guide to pain management and administration of analgesic agents in all patients regardless of age is what the patient says. The elderly patient may obtain more pain relief for a longer time than a younger patient. As a result, smaller, less frequent doses may be required. The American Geriatrics Society (2002) has published clinical practice guidelines for managing chronic pain in elderly patients.
Tricyclic Antidepressant Agents and Anticonvulsant Medications Pain of neurologic origin (eg, causalgia, tumor impingement on a nerve, postherpetic neuralgia) is difficult to treat and in general is not responsive to opioid therapy. When these pain syndromes are accompanied by dysesthesia (burning or cutting pain), they may be responsive to a tricyclic antidepressant or an antiseizure agent. When indicated, tricyclic antidepressant agents, such as amitriptyline (Elavil) or imipramine (Tofranil), are prescribed in doses considerably smaller than those generally used for depression. The patient needs to know that a therapeutic effect may not occur before 3 weeks. Antiseizure medications such as phenytoin (Dilantin) or carbamazepine (Tegretol) also are used in doses lower than those prescribed for seizure disorders. Because a variety of medications can be tried, the nurse should be familiar with the possible side effects and should teach the patient and family how to recognize these effects.
ROUTES OF ADMINISTRATION The route selected for administering an analgesic agent (Table 13-3) depends on the patient’s condition and the desired effect of the medication. Analgesic agents can be administered by parenteral, oral, rectal, transdermal, transmucosal, intraspinal, or epidural routes. Each method of administration has advantages and disadvantages. The route chosen should be based on the patient’s needs.
Parenteral Parenteral administration (intramuscular, intravenous, or subcutaneous) of the analgesic medication produces effects more rapidly than oral administration, but these effects are of shorter
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Table 13-3
CONCEPTS AND CHALLENGES IN PATIENT MANAGEMENT
• Administration Routes for Analgesics
ROUTE
SITE
Parenteral
Intramuscular (IM) Intravenous (IV) Subcutaneous (SC) Oral (PO) Rectal (PR) Skin Oral mucosa Intranasal mucosa Bronchial mucosa Epidural space Spinal canal
Gastrointestinal Transdermal Transmucosal
Epidural Intraspinal
duration. Parenteral administration may be indicated if the patient is not permitted oral intake or is vomiting. Medication administered by the intramuscular route enters the bloodstream more slowly than medication given intravenously and is metabolized slowly. The rate of absorption may be erratic; it depends on the site selected and the amount of body fat. The intravenous route is an alternative to intramuscular injection for many but not all analgesic medications. The intravenous route is the preferred parenteral route in most acute care situations because it is much more comfortable for the patient. In addition, peak serum levels and pain relief occur more rapidly and reliably. Because it peaks rapidly (usually within minutes) and is metabolized quickly, an appropriate intravenous dose will be smaller and prescribed at shorter intervals than an intramuscular dose. Intravenous opioids may be administered by IV push or slow push (eg, over a 5- to 10-minute period) or by continuous infusion with a pump. Continuous infusion provides a steady level of analgesia and is indicated when pain occurs over a 24-hour period (eg, after surgery for the first day or so, or in a patient with prolonged cancer pain who cannot take medication by other routes). The dose of analgesic agent is calculated carefully to relieve pain without producing respiratory depression and other side effects. The subcutaneous route for infusion of opioid analgesic agents is used for patients with severe pain such as cancer pain; it is particularly useful for patients with limited intravenous access who cannot take oral medications, and patients who are managing their pain at home. The dose of opioid that can be infused through this route is limited because of the small volume that can be administered at one time into the subcutaneous tissue. However, this route is often an effective and convenient way to manage pain.
Oral Route If the patient can take medication by mouth, oral administration is preferred over parenteral administration because it is easy, noninvasive, and not painful. Severe pain can be relieved with oral opioids if the doses are high enough (see Table 13-2). In terminally ill patients with prolonged pain, doses may gradually be increased as the disease progresses and causes more pain or as the person builds up a tolerance to the medication. If these higher doses are increased gradually, they usually provide additional pain relief without producing respiratory depression
or sedation. If the route of administration is changed from a parenteral route to the oral route at a dose that is not equivalent in strength (equianalgesic), the smaller oral dose may result in a withdrawal reaction and recurrence of pain.
Rectal Route The rectal route of administration may be indicated in patients who cannot take medications by any other route. The rectal route may also be indicated for patients with bleeding problems, such as hemophilia. The onset of action of opioids administered rectally is unclear but is delayed compared with other routes of administration. Similarly, the duration of action is prolonged.
Transdermal Route The transdermal route has been used to achieve a consistent opioid serum level through absorption of the medication via the skin. This route is most often used for cancer patients who are at home or in hospice care and who have been receiving oral sustained-release morphine. Fentanyl (Duragesic) is the only commercially available transdermal medication. The preparation is a patch consisting of a reservoir containing the medication and a membrane. When the transdermal system is first applied to the skin, the fentanyl, which is fat-soluble, binds to the skin and fat layers. Then it is slowly and systemically absorbed. Therefore, there is a delay in effect while the dermal layer is being saturated. A drug reservoir actually forms in the upper layer of skin. This results in a slowly rising serum level and a slow tapering of the serum level once the patch is removed (see Fig. 13-8). Because it takes 12 to 24 hours for the fentanyl levels to gradually increase from the first patch, the last dose of sustained-release morphine should be given at the same time the first patch is applied (Donner et al., 1996). Transdermal fentanyl is associated with slightly less constipation than oral opioids. Absorption is increased in the febrile patient. A heating pad should never be applied to the area where the patch is applied. Transdermal fentanyl is much more expensive than sustained-release morphine but less costly than methods that deliver parenteral opioids. Once it is determined that switching from other routes of morphine administration to the patch is appropriate, the correct dosage for the patch must be calculated. If the patient uses an opioid other than morphine, conversion to milligrams of oral morphine is the first step. After determining how many milligrams of morphine (or morphine equivalents) the patient has been using over 24 hours, an initial dose of transdermal fentanyl can be calculated. Pasaro (1997) suggests one method of calculating the initial dose of fentanyl: the patient’s daily dose of morphine is divided by two. Thus, the equivalent of 400 mg morphine used per day would be equivalent to 200 g fentanyl per hour. Patients switched from morphine to fentanyl need to be assessed not only for pain and potential side effects but also for dependence, reflected by withdrawal symptoms, which may consist of shivering, a feeling of coldness, sweating, headache, and paresthesia (Puntillo, Casella et al., 1997). Patients may require short-acting opioids for breakthrough pain before the systemic fentanyl level reaches a therapeutic level. These conversions and the conversion-type table in the transdermal fentanyl packet insert should be used only to establish the initial dose of fentanyl when the patient switches from oral morphine to fentanyl (and not vice versa). These tables and equations
Chapter 13 are not meant to be used to determine the dosages of oral morphine for a patient who has been receiving transdermal fentanyl. Many patients will not achieve satisfactory analgesia from the initial dose of transdermal fentanyl and will require an increase in their fentanyl dose to treat breakthrough pain. If the table or equation is used incorrectly to calculate a morphine dose, there is a risk of overdose. If the patient requires a change from transdermal fentanyl back to oral or intravenous morphine (as in the case of surgery), the patch should be removed and intravenous morphine supplied on an assessed need basis. Before applying a new patch, the patient should be carefully checked for any older, forgotten patches. These should be discarded. Patches should be replaced every 72 hours.
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Intraspinal and Epidural Routes
The person with cancer pain who is being cared for at home may be receiving continuous opioids using sustained-release morphine, hydromorphone, oxycodone, transdermal fentanyl, or other medications. These patients often experience short episodes of severe pain (eg, after coughing or moving), or they may experience sudden increases in their baseline pain resulting from a change in their condition. These periods, called breakthrough pain, can be well managed with an oral dose of a short-acting transmucosal opioid that has a rapid onset of action. Currently the only transmucosal opioid available is fentanyl, a lozenge on an applicator stick (often referred to as a lollipop by patients). Currently the only approved and commercially available transmucosal opioid analgesic agents in a nasal spray form are butorphanol (Stadol) and fentanyl. Butorphanol is a complex medication that simultaneously acts to induce or promote (agonist) and inhibit or reverse (antagonist) opioid effects. It works like an opioid agonist and an opioid antagonist at the same time. Butorphanol in any form cannot be combined with other opioids (eg, for cancer breakthrough pain) because the antagonist component will block the action of the opioids the patient is already receiving. The principal use of this agent is for brief, moderate to severe pain, such as migraine headaches. Intranasal fentanyl is useful in cancer-related breakthrough pain. Given in this form, analgesia is achieved within 5 to 10 minutes and was rated as achieving analgesia superior to oral morphine by 50% of patients in one study (Zeppetella, 2000).
Infusion of opioids or local anesthetic agents into the subarachnoid space (intrathecal space or spinal canal) or epidural space has been used for effective control of pain in postoperative patients and those with chronic pain unrelieved by other methods. A catheter is inserted into the subarachnoid or the epidural space at the thoracic or lumbar level for administration of opioid or anesthetic agents (Fig. 13-9). With intrathecal administration, the medication infuses directly into the subarachnoid space and cerebrospinal fluid, which surrounds the spinal cord. With epidural administration, medication is deposited in the dura of the spinal canal and diffuses into the subarachnoid space. It is believed that pain relief from intraspinal administration of opioids is based on the existence of opioid receptors in the spinal cord. Infusion of opioids and local anesthetic agents through an intrathecal or epidural catheter results in pain relief with fewer side effects, including sedation, than with systemic analgesia. Adverse effects associated with intraspinal administration include spinal headache resulting from loss of spinal fluid when the dura is punctured. This is more likely to occur in younger (less than 40 years of age) patients. The dura must be punctured with the intrathecal route, and dural puncture may occur inadvertently with the epidural route. When dural puncture inadvertently occurs, spinal fluid seeps out of the spinal canal. The resultant headache is likely to be more severe with an epidural needle because it is larger than a spinal needle, and therefore more spinal fluid escapes. Although respiratory depression generally peaks 6 to 12 hours after epidural opioids are administered, it can occur earlier or up to 24 hours after the first injection. Depending on the lipophilicity (affinity for body fat) of the opioid injected, the time frame for respiratory depression can be short or long. Morphine is hydrophilic, and the time for peak effect is longer compared to fentanyl, which is a lipophilic opioid. All patients should be monitored closely for at least the first 24 hours after the first injection, longer if changes in respiratory status or level of consciousness occur. Opioid antagonist agents such as naloxone must be available for intravenous use if respiratory depression occurs. The patient is also observed for urinary retention, pruritus, nausea, vomiting, and dizziness. Precautions must be taken to avoid infection at the catheter site and catheter displacement. Only medications without preservatives should be administered
A
B
Transmucosal Route
FIGURE 13-9 Placement of intraspinal catheters for administration of analgesic medications: (A) intrathecal route, (B) epidural route.
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into the subarachnoid or epidural space because of the potential neurotoxic effects of preservatives. During surgery, intrathecal opioids are used almost exclusively after a spinal anesthetic agent is administered. For patients undergoing large abdominal surgical procedures, especially those at risk for postoperative complications, a combination of a general inhaled anesthetic agent for the surgery and a local epidural anesthetic agent and epidural opioids administered after surgery results in excellent pain control with fewer postoperative complications. Patients who have persistent, severe pain that fails to respond to other treatments, or those who obtain pain relief only with the risk of serious side effects, may benefit from medication administered by a long-term intrathecal or epidural catheter. After the physician tunnels the catheter through the subcutaneous tissue and places the inlet (or port) under the skin, the medication is injected through the skin into the inlet and catheter, which delivers the medication directly into the epidural space. The medication may need to be injected several times a day to maintain an adequate level of pain relief. In patients who require more frequent doses or continuous infusions of opioid analgesic agents to relieve pain, an implantable infusion device or pump may be used to administer the medication continuously. The medication is administered at a small, constant dose at a preset rate into the epidural or subarachnoid space. The reservoir of the infusion device stores the medication for slow release and needs to be refilled every 1 or 2 months, depending on the patient’s needs. This eliminates the need for repeated injections through the skin.
!
NURSING ALERT An epidural catheter inserted for pain control is usually managed by the nurse. Baseline information necessary to provide safe and effective pain control includes the level or site of catheter insertion, the medications (eg, local anesthetic agents or opioids) that have been administered, and the medications anticipated in the future. The infusion rate is increased with caution when anesthetic agents are combined with opioids. Sensory deficits can occur and patients must be assessed frequently. An infusion with a lower concentration of anesthetic agent allows for administration of a greater concentration of the opioid with a lower risk of sensory deficits.
NURSING MANAGEMENT OF SIDE EFFECTS Headache resulting from spinal fluid loss may be delayed. Therefore, the nurse needs to assess regularly for headache after either type of catheter is placed. Should headache occur, the patient should remain flat in bed and should be given large amounts of fluids (provided the medical condition allows), and the physician should be notified. An epidural blood patch may be carried out to reduce leakage of spinal fluid. Cardiovascular effects (hypotension and decreased heart rate) may result from relaxation of the vasculature in the lower extremities. Therefore, the nurse assesses frequently for decreases in blood pressure, pulse rate, and urine output. For patients experiencing urinary retention and pruritus, the physician may prescribe small doses of naloxone. The nurse administers these doses in a continuous intravenous infusion that is small enough to reverse the side effects of the opioids without reversing the analgesic effects. Diphenhydramine (Benadryl) may also be used to relieve opioid-related pruritus. PROMOTING HOME AND COMMUNITY-BASED CARE The patient who receives epidural analgesic agents at home and the family must be taught how to administer the prescribed medication using sterile technique and how to assess for infection. The patient and family also need to learn how to recognize side
effects and what to do about them. Although respiratory depression is uncommon, urinary retention may be a problem, and patients and families must be prepared to deal with it if it occurs. Implanted analgesic delivery systems can be safely and confidently used at home only if health care personnel are available for consultation and, possibly, intervention on short notice.
NONPHARMACOLOGIC INTERVENTIONS Although pain medication is the most powerful pain relief tool available to nurses, it is not the only one. Nonpharmacologic nursing activities can assist in relieving pain with usually low risk to the patient. Although such measures are not a substitute for medication, they may be all that is necessary or appropriate to relieve episodes of pain lasting only seconds or minutes. In instances of severe pain that lasts for hours or days, combining nonpharmacologic interventions with medications may be the most effective way to relieve pain.
Cutaneous Stimulation and Massage The gate control theory of pain proposes that the stimulation of fibers that transmit nonpainful sensations can block or decrease the transmission of pain impulses. Several nonpharmacologic pain relief strategies, including rubbing the skin and using heat and cold, are based on this theory. Massage, which is generalized cutaneous stimulation of the body, often concentrates on the back and shoulders. A massage does not specifically stimulate the non-pain receptors in the same receptor field as the pain receptors, but it may have an impact through the descending control system (see earlier discussion). Massage also promotes comfort because it produces muscle relaxation.
Ice and Heat Therapies Ice and heat therapies may be effective pain relief strategies in some circumstances; however, their effectiveness and mechanism of action need further study. Proponents believe that ice and heat stimulate the non-pain receptors in the same receptor field as the injury. For greatest effect, ice should be placed on the injury site immediately after injury or surgery. Ice therapy after joint surgery can significantly reduce the amount of analgesic medication required subsequently. Ice therapy may also relieve pain if applied later. Care must be taken to assess the skin prior to treatment and to protect the skin from direct application of the ice. Ice should be applied to an area for no longer than 20 minutes at a time. This prevents the rebound phenomenon that occurs as the body attempts to warm up, rendering the treatment useless. Long applications of ice may result in frostbite or nerve injury. Both ice and heat therapy must be applied carefully and monitored closely to avoid injuring the skin. Neither therapy should be applied to areas with impaired circulation or used with patients with impaired sensation. Application of heat increases blood flow to an area and contributes to pain reduction by speeding healing. Both dry and moist heat may provide some analgesia, but their mechanisms of action are not well understood. Application of heat to inflamed joints, for example, may provide temporary comfort, but increasing the intra-articular temperature may impair healing (Oosterveld & Rasker, 1994a, 1994b).
Transcutaneous Electrical Nerve Stimulation Transcutaneous electrical nerve stimulation (TENS) uses a batteryoperated unit with electrodes applied to the skin to produce a tingling, vibrating, or buzzing sensation in the area of pain. It has
Chapter 13 been used in both acute and chronic pain relief and is thought to decrease pain by stimulating the non-pain receptors in the same area as the fibers that transmit the pain. This mechanism is consistent with the gate control theory of pain and explains the effectiveness of cutaneous stimulation when applied in the same area as an injury. For example, when TENS is used in a postoperative patient, the electrodes are placed around the surgical wound. Another possible explanation for the effectiveness of TENS is the placebo effect (the patient expects it to be effective). In a review of the literature, Carroll, Tramer, McQuay et al. (1996) found that in 15 of 17 studies with randomized control group designs, TENS was ineffective in relieving postoperative pain. In 17 of 19 studies that did not use this design, the authors of these studies concluded that TENS had a positive analgesic effect. The review of these studies suggests that a placebo effect may explain the effectiveness of TENS.
Distraction Distraction helps relieve both acute and chronic pain (Johnson & Petrie, 1997). Distraction, which involves focusing the patient’s attention on something other than the pain, may be the mechanism responsible for other effective cognitive techniques. Distraction is thought to reduce the perception of pain by stimulating the descending control system, resulting in fewer painful stimuli being transmitted to the brain. The effectiveness of distraction depends on the patient’s ability to receive and create sensory input other than pain. Distraction techniques may range from simple activities, such as watching TV or listening to music, to highly complex physical and mental exercises. Pain relief generally increases in direct proportion to the person’s active participation, the number of sensory modalities used, and the person’s interest in the stimuli. Therefore, the stimulation of sight, sound, and touch is likely to be more effective in reducing pain than is the stimulation of a single sense. Visits from family and friends are effective in relieving pain. Watching an action-packed movie on a large screen with “Surround-Sound” through headphones may be effective (provided the person finds it acceptable). Others may benefit from games and activities (eg, chess) that require concentration. Not all patients obtain pain relief with distraction, especially those in severe pain. With severe pain, the patient may be unable to concentrate well enough to participate in complex physical or mental activities.
Relaxation Techniques Skeletal muscle relaxation is believed to reduce pain by relaxing tense muscles that contribute to the pain. Considerable evidence supports relaxation as effective in relieving chronic low back pain (NIH Technology Assessment Panel, 1995). Few studies, however, support its effectiveness in reducing postoperative pain. This may be due to the relatively small role skeletal muscles play in postoperative pain, or to the need for the patient to practice the relaxation technique for it to be effective. Practicing the technique may not be possible when it is taught only once, immediately before surgery. A patient who already knows a technique for relaxing may only need to be reminded to use it to reduce or prevent increased pain. A simple relaxation technique consists of abdominal breathing at a slow, rhythmic rate. The patient may close both eyes and breathe slowly and comfortably. A constant rhythm can be maintained by counting silently and slowly with each inhalation (“in, two, three”) and exhalation (“out, two, three”). When teaching this technique, the nurse may count out loud with the patient at first. Slow, rhythmic breathing may also be used as a distraction technique. Relaxation techniques, as well as other noninvasive
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pain relief measures, may require practice before the patient becomes skilled in using them. Almost all people with chronic pain can benefit from some method of relaxation. Regular relaxation periods may help to combat the fatigue and muscle tension that occur with and increase chronic pain.
Guided Imagery Guided imagery is using one’s imagination in a special way to achieve a specific positive effect. Guided imagery for relaxation and pain relief may consist of combining slow, rhythmic breathing with a mental image of relaxation and comfort. The nurse instructs the patient to close the eyes and breathe slowly in and out. With each slowly exhaled breath, the patient imagines muscle tension and discomfort being breathed out, carrying away pain and tension and leaving behind a relaxed and comfortable body. With each inhaled breath, the patient imagines healing energy flowing to the area of discomfort. If guided imagery is to be effective, it requires a considerable amount of time to explain the technique and time for the patient to practice it. Usually, the patient is asked to practice guided imagery for about 5 minutes, three times a day. Several days of practice may be needed before the intensity of pain is reduced. Many patients begin to experience the relaxing effects of guided imagery the first time they try it. Pain relief can continue for hours after the imagery is used. The patient needs to be informed that guided imagery may work only for some people. Guided imagery should be used only in combination with all other forms of treatment that have demonstrated effectiveness.
Hypnosis Hypnosis, which has been effective in relieving pain or decreasing the amount of analgesic agents required in patients with acute and chronic pain, may promote pain relief in particularly difficult situations (eg, burns). The mechanism by which hypnosis acts is unclear. Its effectiveness depends on the hypnotic susceptibility of the individual (Farthing, Venturino, Brown et al., 1997). In some cases, hypnosis may be effective in the first session, with effectiveness increasing in additional sessions. In other cases, hypnosis does not work at all. Usually, hypnosis must be induced by a specially skilled person (a psychologist or a nurse with specialized training in hypnosis). Sometimes patients learn to perform self-hypnosis.
Neurologic and Neurosurgical Approaches to Pain Management In some situations, especially with long-term and severe intractable pain, usual pharmacologic and nonpharmacologic methods of pain relief are ineffective. In those situations, neurologic and neurosurgical approaches to pain management may be considered. Intractable pain refers to pain that cannot be relieved satisfactorily by the usual approaches, including medications. Such pain usually is the result of malignancy (especially of the cervix, bladder, prostate, and lower bowel), but it may occur in other conditions, such as postherpetic neuralgia, trigeminal neuralgia, spinal cord arachnoiditis, and uncontrollable ischemia and other forms of tissue destruction. Neurologic and neurosurgical methods available for pain relief include (1) stimulation procedures (intermittent electri-
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cal stimulation of a tract or center to inhibit the transmission of pain impulses), (2) administration of intraspinal opioids (see previous discussion), and (3) interruption of the tracts conducting the pain impulse from the periphery to cerebral integration centers. The latter are destructive or ablative procedures, and their effects are permanent. Ablative procedures are used when other methods of pain relief have failed.
STIMULATION PROCEDURES Electrical stimulation, or neuromodulation, is a method of suppressing pain by applying controlled low-voltage electrical pulses to the different parts of the nervous system. Electrical stimulation is thought to relieve pain by blocking painful stimuli (the gate control theory). This pain-modulating technique is administered by many modes. TENS and dorsal spinal cord stimulation are the most common types of electrical stimulation used. (See previous discussion of TENS.) In addition, there are also brain-stimulating techniques in which electrodes are implanted in the periventricular area of the posterior third ventricle, allowing the patient to stimulate this area to produce analgesia. In spinal cord stimulation, a technique used for the relief of chronic, intractable pain, ischemic pain, and pain from angina, a surgically implanted device allows the patient to apply pulsed electrical stimulation to the dorsal aspect of the spinal cord to block pain impulses (Linderoth & Meyerson, 2002). (The largest accumulation of afferent fibers is found in the dorsal column of the spinal cord.) The dorsal column stimulation unit consists of a radiofrequency stimulation transmitter, a transmitter antenna, a radiofrequency receiver, and a stimulation electrode. The batterypowered transmitter and antenna are worn externally; the receiver and electrode are implanted. A laminectomy is performed above the highest level of pain input, and the electrode is placed in the epidural space over the posterior column of the spinal cord. (The placement of the stimulating systems varies.) A subcutaneous pocket is constructed over the clavicular area or some other site for placement of the receiver. The two are connected by a subcutaneous tunnel. Careful patient selection is necessary, and not all patients receive total pain relief. Deep brain stimulation is performed for special pain problems when the patient does not respond to the usual techniques of pain control. With the patient under local anesthesia, electrodes are introduced through a burr hole in the skull and inserted into a selected site in the brain, depending on the location or type of pain. After the effectiveness of stimulation is confirmed, the implanted electrode is connected to a radiofrequency device or pulsegenerator system operated by external telemetry. It is used in neuropathic pain that may occur with damage or injury that occurred following stroke, brain or spinal cord injuries, or phantom limb pain. Use of deep brain stimulation has decreased and may be related to improved pain control and intraspinal therapies (Rezai & Lozano, 2002).
system is destroyed, resulting in varying amounts of neurologic deficit and incapacity. In time, pain usually returns as a result of either regeneration of axonal fibers or the development of alternative pain pathways. Destructive procedures used to interrupt the transmission of pain include cordotomy and rhizotomy. These procedures are offered if the patient is thought to be near the end of life and will have an improved quality of life as an outcome (Linderoth & Meyerson, 2002). Often these procedures can provide pain relief for the duration of a patient’s life. The use of other methods to interrupt pain transmission is waning since the use of intraspinal therapies and newer pain management treatments are available. CORDOTOMY A cordotomy is the division of certain tracts of the spinal cord (Fig. 13-10). It may be performed percutaneously, by the open method after laminectomy, or by other techniques. Cordotomy is performed to interrupt the transmission of pain (Hodge & Christensen, 2002). Care must be taken to destroy only the sensation of pain, leaving motor functions intact. RHIZOTOMY Sensory nerve roots are destroyed where they enter the spinal cord. A lesion is made in the dorsal root to destroy neuronal dysfunction and reduce nociceptive input. With the advent of microsurgical techniques, the complications are few, with mild sensory deficits and mild weakness (Fig. 13-11).
Nursing Interventions With each of these procedures, patients are provided with written and verbal instructions about their expected effect on pain and on possible untoward consequences. The patient is monitored for
A
Interruption of Pain Pathways As described above, stimulation of a peripheral nerve, the spinal cord, or the deep brain using minute amounts of electricity and a stimulating device is used if all other pharmacologic and nonpharmacologic treatments fail to provide adequate relief. These treatments are reversible. If they need to be discontinued, the nervous system continues to function. Treatments that interrupt the pain pathways, however, are permanent. Pain-conducting fibers can be interrupted at any point from their origin to the cerebral cortex. Some part of the nervous
B
FIGURE 13-10
C
(A) Site of percutaneous C1–C2 cordotomy. (B) Lesion produced by percutaneous C1–C2 cordotomy. (C) Extent of analgesia produced by left C1–C2 percutaneous cordotomy.
Chapter 13
A
B
C
FIGURE 13-11
A rhizotomy may be performed surgically, percutaneously, or chemically, depending on a patient’s condition and needs. The procedure is usually done to relieve severe chest pain, for example, from lung cancer. In (A) a surgical rhizotomy, (B) the spinal roots are divided and banded with a clip to form a lesion and subsequent (C) loss of sensation. Adapted with permission from Loeser, J. D. (ed.) (2000). Bonica’s management of pain (3rd ed.). Philadelphia: Lippincott Williams & Wilkins.
specific effects of each method of pain intervention, both positive and negative. The specific nursing care of patients who undergo neurologic and neurosurgical procedures for the relief of chronic pain depends on the type of procedure performed, its effectiveness in relieving the pain, and the changes in neurologic function that accompany the procedure. After the procedure, the patient’s pain level and neurologic function are assessed. Other nursing interventions that may be indicated include positioning, turning and skin care, bowel and bladder management, and interventions to promote patient safety. Pain management remains an important aspect of nursing care with each of these procedures.
ALTERNATIVE THERAPIES People suffering chronic, debilitating pain are often desperate. Often they will try anything, recommended by anyone, at any price. Information about an array of potential therapies can be found on the Internet and in the self-help section of the bookstore. Therapies specifically recommended for pain from these sources include but are not limited to chelation, therapeutic touch, music therapy, herbal therapy, reflexology, magnetic therapy, electrotherapy, polarity therapy, acupressure, emu oil, pectin therapy, aromatherapy, homeopathy, and macrobiotic dieting. Many of these “therapies” (with the exception of macrobiotic dieting) are probably not harmful. However, they have yet to be proven effective by the standards used to evaluate the effectiveness of medical and nursing interventions. The National Institutes of Health has established an office to examine the effectiveness of alternative therapies. Despite the lack of scientific evidence that these therapies are effective, a patient may find any one of them helpful via the
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placebo response. It is important when caring for a patient who is using or considering using untested therapies (often referred to as alternative therapies) not to diminish the patient’s hope and potential placebo response. This must be weighed against the professional nurse’s responsibility to protect the patient from costly and potentially harmful and dangerous therapies that the patient is not in a position to evaluate scientifically. Problems arise when patients do not find relief but are deprived of conventional therapy because the alternative therapy “should be helping,” or when patients abandon conventional therapy for alternative therapy. In addition, few alternative therapies are free. Desperate patients may risk financial ruin seeking alternative therapies that do not work. The nurse’s role is to help the patient and family understand scientific research and how that differs from anecdotal evidence. Without diminishing the placebo effects the patient may receive, the nurse encourages the patient to assess the effectiveness of the therapy continually using standard pain assessment techniques. In addition, the nurse encourages the patient using alternative therapies to combine them with conventional therapies and to discuss this use with the physician.
Promoting Home and Community-Based Care In preparing the patient and family to manage pain at home, the patient and family need to be taught and guided about what type of pain or discomfort to expect, how long the pain is expected to last, and when the pain indicates a problem that should be reported. The person who has experienced acute pain as a result of injury, illness, procedure, or surgery will probably receive one or more prescriptions for analgesic medication.
TEACHING PATIENTS SELF-CARE The patient and family need to understand the purpose of each medication, the appropriate time to use it, the associated side effects, and the strategies that can be used to prevent these problems. The patient and family often need reassurance that pain can be successfully managed at home. Inadequate control of pain at home is a common reason people seek health care or are readmitted to the hospital. When chronic pain exists, anxiety and fear are often intensified at the time the patient is about to return home. The patient and family are instructed about the techniques for assessing pain, using pain assessment tools, and administering pain medications. These instructions are given verbally and in writing (Chart 13-6). Opportunities are provided for the patient and family members to practice administering the medication until they are comfortable and confident with the procedure. They are instructed about the risks of respiratory and central nervous system depression associated with opioids and ways to assess for these complications. If the medications cause other predictable effects, such as constipation, the instructions include measures for preventing and treating the problem, as described earlier. Steps are taken to ensure that the needed medications are available from the local pharmacy so that the patient receives the medication when required. Education for patients and families must stress the need for keeping analgesic agents away from children, who might mistake them for candy. Elderly patients may become lax about this because no children live in the home, but visiting children can be placed at risk. Additionally, analgesic agents must be kept away from other family members who may take them inadvertently.
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Chart 13-6
• PATIENT EDUCATION At-Home Pain Management Plan
Pain control plan for _____________________________________________________________________________________________________________ At home, I will take the following medicines for pain control: Medicine ____________________ ____________________ ____________________ ____________________
How to take ____________________ ____________________ ____________________ ____________________
How many __________________ __________________ __________________ __________________
How often ____________________ ____________________ ____________________ ____________________
Comments ___________________ ___________________ ___________________ ___________________
Medicines that you may take to help treat side effects: Side effect ________________ ________________
Medicine ________________ ________________
How to take ________________ ________________
How many ________________ ________________
How often ________________ ________________
Comments ________________ ________________
Constipation is a very common problem when taking opioid medications. When this occurs, do the following: • Increase fluid intake (8 to 10 glasses of fluid). • Exercise regularly. • Increase fiber in the diet (bran, fresh fruits, vegetables). • Use a mild laxative, such as milk of magnesia, if no bowel movement in 3 days. • Take _______________ every day at _______________ (time) with a full glass of water. • Use a glycerin suppository every morning (this may help make a bowel movement less painful). Nondrug pain control methods: ______________________________________________________________________________________________________________ ______________________________________________________________________________________________________________ Additional instructions: ______________________________________________________________________________________________________________ ______________________________________________________________________________________________________________ ______________________________________________________________________________________________________________ Important phone numbers: Your doctor ___________________________________________ Your nurse ____________________________________________ Your pharmacy ________________________________________ Emergencies ___________________________________________ Call your doctor or nurse immediately if your pain increases or if you have a new pain. Also call your doctor early for refill of pain medicines. Do not let your medicines get below 3 or 4 days’ supply. Agency for Health Care Policy and Research. (1994). Management of cancer pain. Clinical Practice Guidelines. Rockville, MD: Agency for Health Care Policy and Research, Public Health Service, U.S. Department of Health and Human Services.
Further, analgesic medications should be stored safely and out of sight to prevent others from taking them for their own use or for diverting them to others.
CONTINUING CARE If the patient is to receive parenteral or intraspinal analgesia at home, a referral to a home care nurse is indicated. The home care nurse makes a home visit to assess the patient and to determine if the pain management program is being implemented and if the technique for injecting or infusing the analgesic agent is being carried out safely and effectively. If the patient has an implanted infusion pump in place, the nurse examines the condition of the pump or injection site and may refill the reservoir with medication as prescribed or may supervise family members in the procedure. Any change in the patient’s need for analgesic medications is assessed. In collaboration with the physician, the nurse then assists the patient and family in modifying the medication dose. These efforts enable the patient to obtain adequate pain relief while remaining at home and with family.
As tolerance develops, ever-increasing amounts of opioids are needed. It is important to assure the patient and family that slowly increasing doses will not cause an increased risk of respiratory depression and central nervous system depression, because the patient will become tolerant to these effects also. However, the patient will not become tolerant to the constipating effects of opioids and will require increased efforts to prevent constipation.
Evaluating Pain Management Strategies An important aspect of caring for the patient in pain is reassessing the pain after the intervention has been implemented. The measure’s effectiveness is based on the patient’s assessment of pain, as reflected in pain assessment tools. If the intervention was ineffective, the nurse needs to consider other measures. If these are ineffective, the pain relief goals need to be reassessed in collaboration with the physician. The nurse serves as a patient advocate in obtaining additional pain relief.
Chapter 13 REASSESSMENTS After interventions have had a chance to work, the patient is asked to rate the intensity of pain. This assessment is repeated at appropriate intervals after the intervention and compared with the previous rating. These assessments indicate the effectiveness of the pain relief measures and provide a basis for continuing or modifying the plan of care. See the accompanying Plan of Nursing Care for more information.
Evaluation EXPECTED PATIENT OUTCOMES Expected patient outcomes may include: 1. Achieves pain relief a. Rates pain at a lower intensity (on a scale of 0 to 10) after intervention b. Rates pain at a lower intensity for longer periods
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2. Patient or family administers prescribed analgesic medications correctly a. States correct dose of medication b. Administers correct dose using correct procedure c. Identifies side effects of medication d. Describes actions taken to prevent or correct side effects 3. Uses nonpharmacologic pain strategies as recommended a. Reports practice of nonpharmacologic strategies b. Describes expected outcomes of nonpharmacologic strategies 4. Reports minimal effects of pain and minimal side effects of interventions a. Participates in activities important to recovery (eg, drinking fluids, coughing, ambulating) b. Participates in activities important to self and to family (eg, family activities, interpersonal relationships, parenting, social interaction, recreation, work) c. Reports adequate sleep and absence of fatigue and constipation
Plan of Nursing Care Care of the Patient With Pain Nursing Interventions
Rationale
Expected Outcomes
Nursing Diagnosis: Pain Goal: Relief of pain or decrease in intensity of pain 1. Reassure patient that you know pain is real and will assist him or her in dealing with it. 2. Use pain assessment scale to identify intensity of pain. 3. Assess and record pain and its characteristics: location, quality, frequency, and duration. 4. Administer balanced analgesics as prescribed to promote optimal pain relief.
5. Readminister pain assessment scale. 6. Document severity of patient’s pain on chart. 7. Obtain additional prescriptions as needed. 8. Identify and encourage patient to use strategies that have been successful with previous pain. 9. Teach patient additional strategies to relieve pain and discomfort: distraction, relaxation, cutaneous stimulation, etc. 10. Instruct patient and family about potential side effects of analgesics and their prevention and management.
1. Fear that pain will not be accepted as real increases tension and anxiety and decreases pain tolerance. 2. Provides baseline for assessing changes in pain level and evaluating interventions 3. Data assist in evaluating pain and pain relief and identifying multiple sources and types of pain. 4. Analgesics are more effective if administered early in pain cycle. Simultaneous use of analgesics that work on different portions of the nociceptive system will provide greater pain relief with fewer side effects. 5. Permits assessment of effectiveness of analgesia and identifies need for further action if ineffective 6. Assists in demonstrating need for additional analgesic or alternative approach to pain management 7. Inadequate pain relief results in an increased stress response, suffering, and prolonged hospitalizations. 8. Encourages use of pain relief strategies familiar to and accepted by patient 9. Use of these strategies along with analgesia may produce more effective pain relief. 10. Anticipating and preventing side effects enable the patient to continue analgesia without interruption because of side effects.
• Reports relief that pain is accepted as real • • • • • • •
and that he or she will receive assistance in pain relief Reports lower intensity of pain and discomfort after interventions implemented Reports less disruption from pain and discomfort after use of intervention Uses pain medication as prescribed Identifies effective pain relief strategies Demonstrates use of new strategies to relieve pain and reports their effectiveness Experiences minimal side effects of analgesia without interruption to treat side effects Increases interactions with family and friends
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Critical Thinking Exercises
1.
An 82-year-old woman with cancer has been admitted to a skilled care facility from her home. Her son reports that his mother has become increasingly forgetful and is now unable to manage her medication regimen. He says that she would forget when she took her antidepressant pills and OxyContin. She was so “doped up” that he couldn’t bear to see her that way. She is being treated for cancer pain. Two weeks after admission, a pain assessment reveals a pain intensity of 8 on a 0 to 10 scale; she is refusing to get out of bed. Her son is with her and does not want the nurse to give the breakthrough medication or call the physician to titrate the OxyContin for maximal pain relief. Describe the strategies you would use to provide adequate pain management for this patient and the physiologic factors that need to be considered. Identify strategies that you would use to educate her son about her need for pain management. Identify the ethical issues involved in this situation.
2.
A 45-year-old patient has just returned from the postanesthesia care unit (PACU) after a laparoscopic cholecystectomy. She has a history of rheumatoid arthritis for which she takes celecoxib (Celebrex) 200 mg bid. She rates her pain intensity from the recent surgery as a 6 (on a 0 to 10 scale) and is complaining of severe pain in multiple joints. Discuss the factors contributing to the pain that this patient is experiencing. What would be the best approach to manage her pain? Analyze the effect of her rheumatoid arthritis and joint pain on her postoperative pain and its management.
3.
A 62-year-old man is receiving epidural infusions of an opioid for intractable pain. He will be discharged home, where his daughter will assist in his pain management. Describe the teaching required for the man and his daughter. What side effects should they observe for, and what actions should they take if they occur? How would you modify your discharge teaching plan if the patient lived alone?
4.
A 35-year-old patient with a history of heroin use is admitted to the hospital with multiple stab wounds following an altercation. Two days after extensive surgery to repair his wounds, he reports severe, unrelenting pain and reports that the medication he is receiving (ie, an opioid) is ineffective in diminishing his pain. Several staff members believe that he does not have severe pain and only wants more medication because of his history of drug abuse. Describe how you would address pain relief in this patient, and provide rationale for your actions. How would you address the views of the staff members who believe that the patient should not receive additional medication?
REFERENCES AND SELECTED READINGS Books Agency for Health Care Policy and Research, Public Health Service, Department of Health and Human Services. (1992). Acute pain management: Operative or medical procedures and trauma. Clinical Practice Guidelines. (AHCPR 92-0032). Washington, DC: U.S. Government Printing Office. Agency for Health Care Policy and Research, Public Health Service, Department of Health and Human Services. (1994). Management of cancer pain: Adults. Clinical Practice Guidelines (AHCPR 94-0592). Washington, DC: U.S. Government Printing Office.
American Cancer Society (2001). American Cancer Society’s guide to pain control: Powerful methods to overcome cancer pain. Atlanta: American Cancer Society. American Pain Society. (1999). Principles of analgesic use in the treatment of acute pain and chronic cancer pain (4th ed.). Skokie, IL: Author. Benjamin, L. J., Dampier, C. D., Jacox, A., et al. (1999). Clinical practice guideline for the management of acute and chronic pain in sickle cell disease. American Pain Society Clinical Practice Guidelines series, No 1. Glenview, IL: American Pain Society. Bonica, J. J. (2000). The management of pain (3d ed.). Philadelphia: Lea & Febiger. Fillingim, R. B. (2000). Sex, gender, and pain. Progress in pain research and management, Vol. 17. Seattle: IASP Press. Freeman, L. W., & Lawlis, G. F. (2001). Mosby’s complementary and alternative medicine: A research-based approach. St. Louis: Mosby. Gatchel, R. J., & Turk, D. C. (Eds.). (1999). Psychosocial factors in pain. New York: Guiliford. Harden, R. N., Baron, R., & Janig, W. (2001). Complex regional pain syndrome. Progress in pain research and management, Vol. 22. Seattle: IASP Press. Hodge, C. J., & Christensen, M. (2002). Anterolateral cordotomy. In K. J. Burchiel (Ed.). Surgical management of pain. New York: Thieme. Janig, W. (2001). CRPS-I and CRPS-II: A strategic view. In R. N. Harden, R. Baron, & W. Janig (Eds.). Complex regional pain syndrome. Progress in pain research and management, 22. Seattle: IASP Press. Joint Commission on Accreditation of Healthcare Organizations. (2003). Hospital accreditation standards. Oakbrook Terrace, IL: JCAHO. Kuhn, M. A. (1999). Complementary therapies for health care providers. Philadelphia: Lippincott Williams & Wilkins. Linderoth, B. & Meyerson, B. A. (2002). Spinal cord stimulation: Mechanisms of action. In K. Burchiel (Ed.). Surgical management of pain. New York: Thieme. McCaffery, M., & Pasaro, C. (1999). Pain: Clinical manual for nursing practice (2d ed.). St. Louis: Mosby. Merskey, H., & Bogduk, N. (Eds.). (1994). Classification of chronic pain (2nd ed). International Association for the Study of Pain Taskforce on Taxonomy. Seattle: IASP Press, pp. 209–214. National Institutes of Health. Integration of behavioral and relaxation approaches into the treatment of chronic pain and insomnia. NIH Technology Assessment Statement, Oct. 16–18, 1995. Porth, C. M. (2002). Pathophysiology: Concepts of altered health states (6th ed.). Philadelphia: Lippincott Williams & Wilkins. Rezai, A. R., & Lozano, A. M. (2002). Deep brain stimulation for chronic pain. In K. J. Burchiel (Ed.). Surgical management of pain. New York: Thieme. Salerno, E., & Willens, J. S. (1996). Pain management handbook: An interdisciplinary approach. St. Louis: C. V. Mosby. Wall, P. D., & Melzack, R. (Eds). (1999). Textbook of pain (4th ed.). New York: Churchill Livingstone. Wall, P. D. (1999). Introduction. In P. D. Wall & R. Melzack (Eds.). Textbook of pain. New York: Churchill-Livingstone, pp. 1–8.
Journals Asterisks indicate nursing research articles. Altmaier, E. M., Lehmann, T. R., Russell, D. W., et al. (1992). The effectiveness of psychological interventions for the rehabilitation of low back pain: A randomized controlled trial evaluation. Pain, 49(3), 329–335. American Geriatrics Society Panel on Persistent Pain in Older Persons. (2002). The management of persistent pain in older persons. Journal of the American Geriatrics Society. 50, 1–20. American Society of Pain Management Nurses. (1996). ASPMN position statement: Use of placebos for pain management. http://www.aspmn. org/html/Psplacebo.htm (accessed 1/8/02). Anderson, R., Saiers, J. H., Abram, S., & Schlicht, C. (2001). Accuracy in equianalgesic dosing: Conversion dilemmas. Journal of Pain and Symptom Management, 21(5), 397–406. Brookoff, D. (2000). Chronic pain: 1. A new disease? Hospital Practice, 35(7), 42–59.
Chapter 13 Buffum, M., & Buffum, J. C. (2000). Nonsteroidal anti-inflammatory drugs in the elderly. Pain Management Nursing, 1(2), 40–50. Campbell, J. (1995). Pain: The fifth vital sign. Presidential Address. American Pain Society, Nov. 11, 1995, Los Angeles. Carroll, D., Tramer, M., McQuay, H., et al. (1996). Randomization is important in studies with pain outcomes: Systematic review of transcutaneous electrical nerve stimulation in acute postoperative pain. British Journal of Anaesthesia, 77(6), 798–803. Cleeland, C. S., Gonin, R., Baez, L., et al. (1997). Pain and treatment of pain in minority patients with cancer. Annals of Internal Medicine, 127 (9), 813–816. *Conner, M., & Deane, D. (1995). Patterns of patient-controlled analgesia and intramuscular analgesia. Applied Nursing Research, 8(2), 67–92. Correll, D. J., Viscusi, E. R., Grunwald, Z., & Moore, J. H. (2001). Epidural analgesia compared with intravenous morphine patientcontrolled analgesia: Postoperative outcome measures after mastectomy with immediate TRAM flap breast reconstruction. Regional Anesthesia Pain Medicine, 26 (5), 444–449. Derby, S. A. (1999). Opioid conversion guidelines for managing adult cancer pain. American Journal of Nursing, 99(10), 62–65. Donner, B., Zenz, M., Tryba, M., & Strumpf, M. (1996). Direct conversion from oral morphine to transdermal fentanyl: A multicenter study in patients with cancer pain. Pain, 64(3), 527–534. Douglas, D. B. (1999). Hypnosis: Useful, neglected, available. American Journal of Hospice and Palliative Care, 16 (5), 665–670. DuPen, A. R., DuPen, S., Hansberry, J., et al. (2000). An educational implementation of a cancer pain algorithm for ambulatory care. Pain Management Nursing, 1(4), 116–128. Edwards, R., Augustson, E. M., & Fillingim, R. (2000). Sex-specific effects of pain related anxiety on adjustment to chronic pain. Clinical Journal of Pain, 16(1), 46–53. Edwards, R. R., & Fillingim, R. B. (2000). Age-associated differences in responses to noxious stimuli. Journal of Gerontology Series A: Biological Science & Medical Science, 56(3), M180–185. Farthing, G. W., Venturino, M., Brown, S. W., & Lazar, J. D. (1997). Internal and external distraction in the control of cold-pressor pain as a function of hypnotizability. International Journal of Clinical & Experimental Hypnosis, 45(4), 433–446. Fenstermaker, R. A. (1999). Neurosurgical invasive techniques for cancer pain: A pain specialist’s view. Current Review of Pain, 3(3), 190–197. Ferrell, B. A. (1995). Pain evaluation and management in the nursing home. Annals of Internal Medicine, 123(9), 681–687. *Ferrell, B., Virani, R., Grant, M., & McCaffery, M. (2000). Analysis of pain content in nursing textbooks. Journal of Pain and Symptom Management, 19(3), 216–228. Foley, K. M. (1999). Advances in cancer pain. Archives of Neurology, 56(4), 413–417. Foster, N. E., Baxter, F., Walsh, D. M., et al. (1996). Manipulation of transcutaneous electrical nerve stimulation variables has no effect on two models of experimental pain in humans. Clinical Journal of Pain, 12(4), 301–310. Fries, B. E., Simon, S. E., Morris, J. N., et al. (2001). Pain in U.S. nursing homes: validating a pain scale for the minimum data set. Gerontologist, 41(2), 173–179. Gatchel, R. D., Polatin, P. B., Mayer, T. G., & Carcy, P. D. (1994). Psychopathology and the rehabilitation of patients with chronic low back pain disability. Archives of Physical Medicine and Rehabilitation, 75(6), 666–670. Gordon, D. B., Pellino, T. A., Enloe, M. G., & Foley, D. K. (2000). A nurse-run inpatient pain consultation service. Pain Management Nursing, 1(2), 29–33. Gordon, D. B., & Ward, S. E. (1995). Correcting patient misconceptions about pain. American Journal of Nursing, 95(7), 43–45. Holleran, R. S. (2002). The problem of pain in emergency care. Nursing Clinics of North America, 37(1), 67–78. Hicks, C. L., von Baeyer, C. L., Spafford, P. A., et al. (2001). The Faces Pain Scale-Revised: Toward a common metric in pediatric pain measurement. Pain, 93(2), 173–183. Hrobjartsson, A., & Gotzsche, P. C. (2001). Is placebo powerless? An analysis of clinical trials comparing placebo with no treatment. New England Journal of Medicine, 344(21), 1594–1602.
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Hunter, M., McDowell, L., Hennessy, R., & Cassey, J. (2000). An evaluation of the Faces Pain Scale with young children. Journal of Pain and Symptom Management, 20(2), 122–129. Janig, W. (2001). CRPS-I and CRPS-II: A strategic view. In Harden, R. N., Baron, R., & Janig, W. (Eds.). Complex regional pain syndrome. Progress in pain research and management, Vol. 22. Seattle: IASP Press. Johnson, M. H., & Petrie, S. M. (1997). The effects of distraction on exercise and cold presser tolerance for chronic low back pain sufferers. Pain, 69(1–2), 43–48. Keefe, F. J., Lefebvre, J. C., & Starr, K. R. (1996). From the gate control theory to the neuromatrix: Revolution or evolution? Pain Forum, 5(2), 143–146. Keefe, F. J., & Williams, D. A. (1990). A comparison of coping strategies in chronic pain in patients in different age groups. Journal of Gerontology, 45(4), 161–165. Kelly, A. M. (1998). Does the clinically significant difference in visual analog scale pain scores vary with gender, age, or cause of pain? Academy of Emergency Medicine, 5(11), 1086–1090. Keogh, E., Ellery, D., Hunt, C., & Hannent, I. (2001). Selective attentional bias for pain-related stimuli amongst fearful individuals. Pain, 91(1–2), 91–100. *Knapp-Spooner, C., Karlik, B. A., Pontieri-Lewis, V., & Yarcheski, A. (1995). Efficacy of patient-controlled analgesia in women cholecystectomy patients. International Journal of Nursing Studies, 32(5), 434–442. Lamberg, L. (1999). Patients in pain need round-the-clock care. Journal of the American Medical Association, 281(8), 689–692. Lasch, K. E. (2000). Culture, pain and culturally sensitive pain care. Pain Management Nursing, 1(3), S1, 16–22. Lasch, K. E., Wilkes, G., Montuori, L. M., et al. (2000). Using focus group methods to develop multicultural cancer patient education materials. Pain Management Nursing, 1(4), 129–138. Li, S. F., Greenwald, P. W., Gennis, P., et al. (2001). Effect of age on acute pain perception of a standardized stimulus in the emergency department. Annals of Emergency Medicine, 38(6), 644–647. Loeb, J. L. (1999). Pain management in long-term care. American Journal of Nursing, 99(2), 48–52. Lynn, J., Teno, J. M., Phillips, R. S., et al. (1997). Perceptions by family members of the dying experience of older and seriously ill patients. Annals of Internal Medicine, 126(2), 97–106. *Malek, C. J. (1996). Pain management: Documenting the decisionmaking process. Nursing Case Management, 1(2), 64–74. Mayer, D. M., Torma, L., Byock, I., & Norris, K. (2001). Speaking the language of pain. American Journal of Nursing, 101(2), 44–49. McCaffery, M., & Ferrell, B. R. (1997). Nurses’ knowledge of pain assessment and management: How much progress have we made? Journal of Pain Symptom Management, 14(3), 175–188. *McCaffery, M., Ferrell, B. R., & Pasaro, C. (2000). Nurses’ personal opinions about patients’ pain and their effect on recorded assessments and titration of opioid doses. Pain Management Nursing, 1(3), 79–87. McCaffery, M., & Pasero, C. (2001). Stigmatizing patients as addicts. American Journal of Nursing, 101(5), 77–79. McCracken, L. M., & Iverson, G. L. (2001). Predicting complaints of impaired cognitive functioning in patients with chronic pain. Journal of Pain and Symptom Management, 21(5), 392–396. *McNeill, J. A., Sherwood, G. D., Starck, P. L., & Nieto, B. (2001). Pain management outcomes for hospitalized Hispanic patients. Pain Management Nursing, 2(4), 25–36. Melzack, R. (1996). Gate control theory: On the evolution of pain concepts. Pain Forum, 5(1), 128–138. Meuser, T., Pietruck, C., Radruch, L., Stute, P., Lehmann, K. A., & Grond, S. (2001). Symptoms during cancer pain treatment following WHO guidelines: A longitudinal follow-up study of symptom prevalence, severity and etiology. Pain, 93(3), 247–257. Miaskowski, C. (2000). The impact of age on a patient’s perception of pain and ways it can be managed. Pain Management Nursing, 1(3), S1, 2–7. *Miaskowski, C., & Dibble, S. L. (1995). The problem of pain in outpatients with breast cancer. Oncology Nursing Forum, 22(5), 791–797. Morin, C., Lund, J. P., Villarroel, T., et al. (2000). Differences between the sexes in post-surgical pain. Pain, 85(1–2), 79–85.
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National Institutes of Health. (1997). Acupuncture. NIH Consensus Statement, 15(5), 1–34. NIH Technology Assessment Panel on Integration of Behavioral and Relaxation Approaches into the Treatment of Chronic Pain and Insomnia. (1995). Integration of behavioral and relaxation approaches into the treatment of chronic pain and insomnia. Journal of the American Medical Association, 276(4), 313–318. North, R., & Levy R. (1994). Consensus conference on the neurosurgical management of pain. Neurosurgery, 34(4), 756–760. Oosterveld, F. G. & Rasker, J. J. (1994a). Effects of local heat and cold treatment on surface and articular temperature of arthritic knees. Arthritis & Rheumatism, 37(11), 1578–582. Oosterveld, F. G. & Rasker, J. J. (1994b). Treating arthritis with locally applied heat or cold. Seminars in Arthritis & Rheumatism, 24(2), 82–90. Panke, J. T. (2002). Difficulties in managing pain at the end of life. American Journal of Nursing, 102(7), 26–33. Pasaro, C. L. (1997). Using the Faces scale to assess pain. American Journal of Nursing, 97(7), 19–20. Pasaro, C., & McCaffery, M. (2001). The lidocaine patch. American Journal of Nursing, 101(3), 22–23. Pasaro, C., & McCaffery, M. (2001). Selective COX-2 inhibitors. American Journal of Nursing, 101(4), 55–56. Pasaro, C., & McCaffery, M. (2002). Monitoring sedation American Journal of Nursing, 102(2), 67–69. Pasaro, C. (2002). Subcutaneous opioid infusion. American Journal of Nursing, 102(7), 61–62. Pasaro, C., & Montgomery, R. (2002). Intravenous fentanyl. American Journal of Nursing, 102(4), 73–76. Peloso, P. M. (2000). NSAIDs: A Faustian bargain. American Journal of Nursing, 100(6), 34–39. Perez, R. S. G. M., Kwakkel, G., Zuurmond, W. W. A., & de Lange, J. J. (2001). Treatment of reflex sympathetic dystrophy (CRPS type I): A research synthesis of 21 randomized clinical trials. Journal of Pain and Symptom Management, 21(6), 511–526. Perin, M. L. (2000). Corticosteroids for cancer pain. American Journal of Nursing, 100(4), 15–16. Plaisance, L., & Ellis, J. A. (2002). Opioid-induced constipation. American Journal of Nursing, 102(3), 72–73. Pollo, A., Amanzio, M., Arslanina, A., et al. (2001). Response expectancies in placebo analgesia and their clinical relevance. Pain, 93(1), 77–84. Porter, J., & Jick, H. (1980). Addiction rare in patients treated with narcotics. New England Journal of Medicine, 302(2), 123. Puig, M. M., & Montes, A. (1998). Opioids: From receptors to clinical application. Current Review of Pain, 2(4), 243–241. *Puntillo, K., Casella, W., & Reid, M. (1997). Opioid and benzodiazepine tolerance and dependence: Application of theory to critical care practice. Heart & Lung, 26(4), 317–324. *Puntillo, K. A., Miaskowski, C., Kehrle, K., et al. (1997). Relationship between behavioral and physiological indicators of pain, critical care patients’ self-reports of pain, and opioid administration. Critical Care Medicine, 25(7), 1159–1166. Raymond, I., Nielsen, T. A., Lauigne, G., et al. (2001). Quality of sleep and its daily relationship to pain intensity in hospitalized adult burn patients. Pain, 92(3), 381–388. Rhiner, M., & Kedziera, P. (1999). Managing breakthrough pain. A new approach. American Journal of Nursing, 99(3), Supplement, 1–12. Rhudy, J. L., & Meagher, M. W. (2000). Fear and anxiety: Divergent effects on human pain thresholds. Pain, 84(1), 65–75. Riley, J. L., Robinson, M. E., Wade, J. B., et al. (2001). Sex differences in negative emotional response to chronic pain. Journal of Pain, 2(6), 354–359. Robinsion, M. E., Riley, J. L., Meyers, C. D., et al. (2001). Gender role expectations of pain. Relationship to sex differences in pain. Journal of Pain, 2(5), 251–257. *Simpson, T., Lee, E. R., & Cameron, C. (1996). Relationships among sleep dimensions and factors that impair sleep after cardiac surgery. Research in Nursing & Health, 19(3), 213–223.
Slaughter, A., Pasaro, C., & Manworren, R. (2002). Unacceptable pain levels. American Journal of Nursing, 102(5), 75–77. SUPPORT Principal Investigators. (1995). A controlled trial to improve care for seriously ill hospitalized patients: The study to understand prognoses and preferences for outcomes and risks of treatments (SUPPORT). Journal of the American Medical Association, 274(20), 1591–1598. Thomas, T., Robinson, C., Champion, D., et al. (1998). Prediction and assessment of the severity of post-operative pain and of satisfaction with management. Pain, 75(2–3), 177–185. Tucker, K. L. (2001). Deceptive placebo administration. American Journal of Nursing, 101(8), 55–56. Uomoto, J. M., & Esselman, P. C. (1993). Traumatic brain injury and chronic pain: Differential types and rates by head injury severity. Archives of Physical Medicine and Rehabilitation, 74(1), 61–64. Unruh, A. M., Ritchie, J., & Merskey, H. (1999). Does gender affect appraisal of pain and pain coping strategies? Clinical Journal of Pain, 15(1), 31–40. Vallerand, A. H., & Polomano, R. C. (2000). The relationship of gender to pain. Pain Management Nursing, 1(3, suppl), 8–15. Walker, B., Shafer, M., Henzi, I. & Tramer, M. R. (2002). Efficacy and safety of patient-controlled opioid analgesia for postoperative pain. A quantitative systematic review. Acta Anaesthesiology Scandinavia, 45(7), 795–804. *Ward, S. E., Berry, P. E., & Misiewicz, H. (1996). Concerns about analgesia among patients and family caregivers in a hospice setting. Research in Nursing & Health, 19(3), 205–211. Washington, L. L., Gibson, S. J., & Helme, R. D. (2000). Age-related differences in endogenous analgesic response to repeated cold water immersion in human volunteers. Pain, 89(1), 89–96. *Watt-Watson, J., Garfinkel, P., Gallop, R., et al. (2000). The impact of nurses’ empathetic responses on patients’ pain management in acute care. Nursing Research, 49(4), 191–200. Weiner, D., Peterson, B., Ladd, K., McConnell, E., & Keefe, F. (1999). Pain in nursing home residents: An exploration of prevalence, staff perspectives, and practical aspects of measurement. Clinical Journal of Pain, 15(2), 92–101. *Zalon, M. L. (1997). Pain in frail, elderly women after surgery. Image: Journal of Nursing Scholarship, 29(1), 21–26. Zeppetella, G. (2000). An assessment of the safety, efficacy, and acceptability of intranasal fentanyl citrate in the management of breakthrough pain: A pilot study. Journal of Pain and Symptom Management, 20(4), 253–258.
RESOURCES AND WEBSITES American Academy of Pain Management, 13947 Mono Way #A, Sonora, CA 95370; (209) 533-9744; http://www.aapainmanage.org. American Chronic Pain Association, P.O. Box 850, Rocklin, CA 95677; (800) 533-3231; http://www.theacpa.org. American Pain Foundation, 201 N. Charles Street, Suite 710, Baltimore, MD 21201; (888) 615-7246; http://www.painfoundation.org. American Pain Society, 4700 W. Lake Street, Glenview, IL 60025; (847) 375-4715; http://www.ampainsoc.org. American Society of Pain Management Nurses, 7794 Grow Drive, Pensacola, FL 32514; (222) 34ASPMN; fax (850) 484-8762; http://www.aspmn.org. International Pain Foundation, 909 NE 43rd St., Room 306, Seattle, WA 98105-6020; (206) 547-6409; fax (206) 547-1703; http:// dasnetO2.dokkyomed.ac.ip/IASPM/IASP.html; e-mail: IASP@locke. hs. washington.ed. Last Acts: an initiative for care and caring at the end of life. Includes “Innovations in End-of-Life Care,” an international journal and on-line forum: http://www.lastacts.org. National Hospice Organization, Suite 901, 1901 N. Moore St., Arlington, VA 22209; (703) 243-5900; http://www.nho.org. “Pain Control,” a monthly column in American Journal of Nursing.
Chapter
14 ●
Fluid and Electrolytes: Balance and Distribution
LEARNING OBJECTIVES
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On completion of this chapter, the learner will be able to: 1. Differentiate between osmosis, diffusion, filtration, and active 2. 3. 4. 5.
6. 7. 8. 9. 10. 11.
transport. Describe the role of the kidneys, lungs, and endocrine glands in regulating the body’s fluid composition and volume. Identify the effects of aging on fluid and electrolyte regulation. Plan effective care of patients with the following imbalances: fluid volume deficit and fluid volume excess; sodium deficit (hyponatremia) and sodium excess (hypernatremia); potassium deficit (hypokalemia) and potassium excess (hyperkalemia). Describe the etiology, clinical manifestations, management, and nursing interventions for the following imbalances: calcium deficit (hypocalcemia) and calcium excess (hypercalcemia); magnesium deficit (hypomagnesemia) and magnesium excess (hypermagnesemia); phosphorus deficit (hypophosphatemia) and phosphorus excess (hyperphosphatemia); chloride deficit (hypochloremia) and chloride excess (hyperchloremia). Explain the role of the lungs, kidneys, and chemical buffers in maintaining acid–base balance. Compare metabolic acidosis and alkalosis with regard to causes, clinical manifestations, diagnosis, and management. Compare respiratory acidosis and alkalosis with regard to causes, clinical manifestations, diagnosis, and management. Interpret arterial blood gas measurements. Demonstrate a safe and effective procedure of venipuncture. Describe measures used for preventing complications of intravenous therapy.
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luid and electrolyte balance is a dynamic process that is crucial for life. Potential and actual disorders of fluid and electrolyte balance occur in every setting, with every disorder, and with a variety of changes that affect well people (eg, increased fluid and sodium loss with strenuous exercise and high environmental temperature; inadequate intake of fluid and electrolytes) as well as those who are ill.
Fundamental Concepts The nurse needs to understand the physiology of fluid and electrolyte balance and acid–base balance to anticipate, identify, and respond to possible imbalances in each. The nurse also must use effective teaching and communication skills to help prevent and treat various fluid and electrolyte disturbances.
AMOUNT AND COMPOSITION OF BODY FLUIDS Approximately 60% of a typical adult’s weight consists of fluid (water and electrolytes). Factors that influence the amount of body fluid are age, gender, and body fat. In general, younger people have a higher percentage of body fluid than older people, and men have proportionately more body fluid than women. Obese people have less fluid than thin people because fat cells contain little water. Body fluid is located in two fluid compartments: the intracellular space (fluid in the cells) and the extracellular space (fluid outside the cells). Approximately two thirds of body fluid is in the intracellular fluid (ICF) compartment and is located primarily in the skeletal muscle mass. The extracellular fluid (ECF) compartment is further divided into the intravascular, interstitial, and transcellular fluid spaces. The intravascular space (the fluid within the blood vessels) contains plasma. Approximately 3 L of the average 6 L of blood volume is made up of plasma. The remaining 3 L is made up of erythrocytes, leukocytes, and thrombocytes. The interstitial space contains the fluid that surrounds the cell and totals about 11 to 12 L in an adult. Lymph is an example of interstitial fluid. The transcellular space is
the smallest division of the ECF compartment and contains approximately 1 L of fluid at any given time. Examples of transcellular fluid are cerebrospinal, pericardial, synovial, intraocular, and pleural fluids; sweat; and digestive secretions. Body fluid normally shifts between the two major compartments or spaces in an effort to maintain an equilibrium between the spaces. Loss of fluid from the body can disrupt this equilibrium. Sometimes fluid is not lost from the body but is unavailable for use by either the ICF or ECF. Loss of ECF into a space that does not contribute to equilibrium between the ICF and the ECF is referred to as a third-space fluid shift, or “third spacing” for short. An early clue of a third-space fluid shift is a decrease in urine output despite adequate fluid intake. Urine output decreases because fluid shifts out of the intravascular space; the kidneys then receive less blood and attempt to compensate by decreasing urine output. Other signs and symptoms of third spacing that indicate an intravascular fluid volume deficit include increased heart rate, decreased blood pressure, decreased central venous pressure, edema, increased body weight, and imbalances in fluid intake and output (I&O). Third-space shifts occur in ascites, burns, peritonitis, bowel obstruction, and massive bleeding into a joint or body cavity.
Electrolytes Electrolytes in body fluids are active chemicals (cations, which carry positive charges, and anions, which carry negative charges). The major cations in body fluid are sodium, potassium, calcium, magnesium, and hydrogen ions. The major anions are chloride, bicarbonate, phosphate, sulfate, and proteinate ions. These chemicals unite in varying combinations. Therefore, electrolyte concentration in the body is expressed in terms of milliequivalents (mEq) per liter, a measure of chemical activity, rather than in terms of milligrams (mg), a unit of weight. More specifically, a milliequivalent is defined as being equivalent to the electrochemical activity of 1 mg of hydrogen. In a solution, cations and anions are equal in mEq/L. Electrolyte concentrations in the ICF differ from those in the ECF, as reflected in Table 14-1. Because special techniques are
Glossary acidosis: an acid–base imbalance characterized by an increase in H+ concentration (decreased blood pH). A low arterial pH due to reduced bicarbonate concentration is called metabolic acidosis; a low arterial pH due to increased PCO2 is respiratory acidosis active transport: physiologic pump that moves fluid from an area of lower concentration to one of higher concentration; active transport requires adenosine triphosphate (ATP) for energy alkalosis: an acid–base imbalance characterized by a reduction in H+ concentration (increased blood pH). A high arterial pH with increased bicarbonate concentration is called metabolic alkalosis; a high arterial pH due to reduced PCO2 is respiratory alkalosis diffusion: the process by which solutes move from an area of higher concentra-
tion to one of lower concentration; does not require expenditure of energy hydrostatic pressure: the pressure created by the weight of fluid against the wall that contains it. In the body, hydrostatic pressure in blood vessels results from the weight of fluid itself and the force resulting from cardiac contraction. hypertonic solution: a solution with an osmolality higher than that of serum hypotonic solution: a solution with an osmolality lower than that of serum isotonic solution: a solution with the same osmolality as serum and other body fluids. Osmolality falls within normal range for serum (280–300 mOsm/kg). osmolality: the number of osmoles (the standard unit of osmotic pressure) per kilogram of solution. Expressed as mOsm/kg. Used more often in clinical practice than the
term osmolarity to evaluate serum and urine. In addition to urea and glucose, sodium contributes the largest number of particles to osmolality. osmolarity: the number of osmoles, the standard unit of osmotic pressure per liter of solution. It is expressed as milliosmoles per liter (mOsm/L); describes the concentration of solutes or dissolved particles. osmosis: the process by which fluid moves across a semipermeable membrane from an area of low solute concentration to an area of high solute concentration; the process continues until the solute concentrations are equal on both sides of the membrane. tonicity: the measurement of the osmotic pressure of a solution; another term for osmolality
Chapter 14
Table 14-1
• Approximate Major Electrolyte Content in Body Fluid
ELECTROLYTES
Extracellular Fluid (Plasma) Cations Sodium (Na) Potassium (K) Calcium (Ca++) Magnesium (Mg++) Total cations Anions Chloride (Cl−) Bicarbonate (HCO3−) Phosphate (HPO4−−) Sulfate (SO4−−) Organic acids Proteinate Total anions Intracellular Fluid Cations Potassium (K+) Magnesium (Mg++) Sodium (Na+) Total cations Anions Phosphates and sulfates Bicarbonate (HCO3−) Proteinate Total anions
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251
REGULATION OF BODY FLUID COMPARTMENTS Osmosis and Osmolality
MEQ/L
142 5 5 2 154 103 26 2 1 5 17 154
150 40 10 200 150 10 40 200
When two different solutions are separated by a membrane that is impermeable to the dissolved substances, fluid shifts through the membrane from the region of low solute concentration to the region of high solute concentration until the solutions are of equal concentration; this diffusion of water caused by a fluid concentration gradient is known as osmosis (Fig. 14-1A). The magnitude of this force depends on the number of particles dissolved in the solutions, not on their weights. The number of dissolved particles contained in a unit of fluid determines the osmolality of a solution, which influences the movement of fluid between the fluid compartments. Tonicity is the ability of all the solutes to cause an osmotic driving force that promotes water movement from one compartment to another (Porth, 2002). The control of tonicity determines the normal state of cellular hydration and cell size. Sodium, mannitol, glucose, and sorbitol are effective osmoles (capable of affecting water movement). Three other terms are associated with osmosis: osmotic pressure, oncotic pressure, and osmotic diuresis.
• Osmotic pressure is the amount of hydrostatic pressure • •
needed to stop the flow of water by osmosis. It is primarily determined by the concentration of solutes. Oncotic pressure is the osmotic pressure exerted by proteins (eg, albumin). Osmotic diuresis occurs when the urine output increases due to the excretion of substances such as glucose, mannitol, or contrast agents in the urine.
Diffusion required to measure electrolyte concentrations in the ICF, it is customary to measure the electrolytes in the most accessible portion of the ECF, namely the plasma. Sodium ions, which are positively charged, far outnumber the other cations in the ECF. Because sodium concentration affects the overall concentration of the ECF, sodium is important in regulating the volume of body fluid. Retention of sodium is associated with fluid retention, and excessive loss of sodium is usually associated with decreased volume of body fluid. As shown in Table 14-1, the major electrolytes in the ICF are potassium and phosphate. The ECF has a low concentration of potassium and can tolerate only small changes in potassium concentrations. Therefore, release of large stores of intracellular potassium, typically caused by trauma to the cells and tissues, can be extremely dangerous. The body expends a great deal of energy maintaining the high extracellular concentration of sodium and the high intracellular concentration of potassium. It does so by means of cell membrane pumps that exchange sodium and potassium ions. Normal movement of fluids through the capillary wall into the tissues depends on hydrostatic pressure (the pressure exerted by the fluid on the walls of the blood vessel) at both the arterial and the venous ends of the vessel and the osmotic pressure exerted by the protein of plasma. The direction of fluid movement depends on the differences in these two opposing forces (hydrostatic versus osmotic pressure). In addition to electrolytes, the ECF transports other substances, such as enzymes and hormones. It also carries blood components, such as red and white blood cells, throughout the body.
Diffusion is the natural tendency of a substance to move from an area of higher concentration to one of lower concentration (see Fig. 14-1B). It occurs through the random movement of ions and molecules. Examples of diffusion are the exchange of oxygen and carbon dioxide between the pulmonary capillaries and alveoli and the tendency of sodium to move from the ECF compartment, where the sodium concentration is high, to the ICF, where its concentration is low.
Filtration Hydrostatic pressure in the capillaries tends to filter fluid out of the vascular compartment into the interstitial fluid. Movement of water and solutes occurs from an area of high hydrostatic pressure to an area of low hydrostatic pressure. Filtration allows the kidneys to filter 180 L of plasma per day. Another example of filtration is the passage of water and electrolytes from the arterial capillary bed to the interstitial fluid; in this instance, the hydrostatic pressure is furnished by the pumping action of the heart.
Sodium–Potassium Pump As stated earlier, the sodium concentration is greater in the ECF than in the ICF, and because of this, sodium tends to enter the cell by diffusion. This tendency is offset by the sodium–potassium pump, which is located in the cell membrane and actively moves sodium from the cell into the ECF. Conversely, the high intracellular potassium concentration is maintained by pumping potassium into the cell. By definition, active transport implies that
Unit 3
252
CONCEPTS AND CHALLENGES IN PATIENT MANAGEMENT
Semipermeable membrane
Fluid
High solute concentration, low fluid concentration and A high osmotic pressure
Low solute concentration, high fluid concentration and low osmotic pressure Semipermeable membrane
Solutes
Fluid
B
High solute concentration
Low solute concentration
FIGURE 14-1
(A) Osmosis: movement of fluid to area of high solute concentration and eventual equalization of solute concentration. (B) Diffusion: movement of fluid and solutes and equalization of solute concentration.
energy must be expended for the movement to occur against a concentration gradient.
ROUTES OF GAINS AND LOSSES Water and electrolytes are gained in various ways. A healthy person gains fluids by drinking and eating. In patients with some disorders, fluids may be provided by the parenteral route (intravenously or subcutaneously) or by means of an enteral feeding tube in the stomach or intestine.
!
NURSING ALERT When fluid balance is critical, all routes of gain and all routes of loss must be recorded and all volumes compared. Organs of fluid loss include the kidneys, skin, lungs, and gastrointestinal (GI) tract.
Kidneys The usual daily urine volume in the adult is 1 to 2 L. A general rule is that the output is approximately 1 mL of urine per kilogram of body weight per hour (1 mL/kg/h) in all age groups.
temperature. Continuous water loss by evaporation (approximately 600 mL/day) occurs through the skin as insensible perspiration, a nonvisible form of water loss. Fever greatly increases insensible water loss through the lungs and the skin, as does loss of the natural skin barrier (through major burns, for example).
Lungs The lungs normally eliminate water vapor (insensible loss) at a rate of approximately 400 mL every day. The loss is much greater with increased respiratory rate or depth, or in a dry climate.
GI Tract The usual loss through the GI tract is only 100 to 200 mL daily, even though approximately 8 L of fluid circulates through the GI system every 24 hours (called the GI circulation). Because the bulk of fluid is reabsorbed in the small intestine, diarrhea and fistulas cause large losses. In healthy people, the daily average intake and output of water are approximately equal (Table 14-2).
Skin
LABORATORY TESTS FOR EVALUATING FLUID STATUS
Sensible perspiration refers to visible water and electrolyte loss through the skin (sweating). The chief solutes in sweat are sodium, chloride, and potassium. Actual sweat losses can vary from 0 to 1,000 mL or more every hour, depending on the environmental
Osmolality reflects the concentration of fluid that affects the movement of water between fluid compartments by osmosis. Osmolality measures the solute concentration per kilogram in blood and urine. It is also a measure of a solution’s ability to cre-
Chapter 14
Table 14-2
• Average Daily Intake and Output in an Adult OUTPUT
INTAKE
Oral liquids Water in food Water produced by metabolism
1,300 mL 1,000 mL 300 mL
Total gain*
2,600 mL
Urine Stool Insensible Lungs Skin Total loss*
1,500 mL 200 mL 300 mL 600 mL 2,600 mL
*Approximate volumes
ate osmotic pressure and affect the movement of water. Serum osmolality primarily reflects the concentration of sodium. Urine osmolality is determined by urea, creatinine, and uric acid. When measured with serum osmolality, urine osmolality is the most reliable indicator of urine concentration. Osmolality is reported as milliosmoles per kilogram of water (mOsm/kg). Osmolarity, another term that describes the concentration of solutions, is measured in milliosmoles per liter (mOsm/L). The term “osmolality,” however, is used more often in clinical practice. Normal serum osmolality is 280 to 300 mOsm/kg, and normal urine osmolality is 250 to 900 mOsm/kg. Sodium predominates in ECF osmolality and holds water in this compartment. Factors that increase and decrease serum and urine osmolality are identified in Table 14-3. Serum osmolality may be measured directly through laboratory tests or estimated at the bedside by doubling the serum sodium level or by using the following formula: Na+ × 2 =
Glucose BUN + = Approximate value of serum osmolality 18 3
The calculated value usually is within 10 mOsm of the measured osmolality. Urine specific gravity measures the kidneys’ ability to excrete or conserve water. The specific gravity of urine is compared to the weight of distilled water, which has a specific gravity of 1.000. The normal range of specific gravity is 1.010 to 1.025. Urine specific gravity can be measured at the bedside by placing a calibrated
Table 14-3
• Comparison of Serum and Urine Osmolality
FLUID
Serum (275–300 mOsm/kg)
Urine (250–900 mOsm/kg)
FACTORS INCREASING OSMOLALITY
FACTORS DECREASING OSMOLALITY
Free water loss Diabetes insipidus Sodium overload Hyperglycemia Uremia Fluid volume deficit SIADH HF Acidosis
SIADH Renal failure Diuretic use Adrenal insufficiency Fluid volume excess Diabetes insipidus
SIADH, syndrome of inappropriate antidiuretic hormone; HF, heart failure.
Fluid and Electrolytes: Balance and Distribution
253
hydrometer or urinometer in a cylinder of approximately 20 mL of urine. Specific gravity can also be assessed with a refractometer or dipstick with a reagent for this purpose. Specific gravity varies inversely with urine volume; normally, the larger the volume of urine, the lower the specific gravity. Specific gravity is a less reliable indicator of concentration than urine osmolality; increased glucose or protein in urine can cause a falsely high specific gravity. Factors that increase or decrease urine osmolality are the same for urine specific gravity. Blood urea nitrogen (BUN) is made up of urea, an end product of metabolism of protein (from both muscle and dietary intake) by the liver. Amino acid breakdown produces large amounts of ammonia molecules, which are absorbed into the bloodstream. Ammonia molecules are converted to urea and excreted in the urine. The normal BUN is 10 to 20 mg/dL (3.5–7 mmol/L). The BUN level varies with urine output. Factors that increase BUN include decreased renal function, GI bleeding, dehydration, increased protein intake, fever, and sepsis. Those that decrease BUN include end-stage liver disease, a low-protein diet, starvation, and any condition that results in expanded fluid volume (eg, pregnancy). Creatinine is the end product of muscle metabolism. It is a better indicator of renal function than BUN because it does not vary with protein intake and metabolic state. The normal serum creatinine is approximately 0.7 to 1.5 mg/dL (SI: 60–130 mmol/L); however, its concentration depends on lean body mass and varies from person to person. Serum creatinine levels increase when renal function decreases. Hematocrit measures the volume percentage of red blood cells (erythrocytes) in whole blood and normally ranges from 44% to 52% for males and 39% to 47% for females. Conditions that increase the hematocrit value are dehydration and polycythemia; those that decrease hematocrit are overhydration and anemia. Urine sodium values change with sodium intake and the status of fluid volume (as sodium intake increases, excretion increases; as the circulating fluid volume decreases, sodium is conserved). Normal urine sodium levels range from 50 to 220 mEq/24 h (50–220 mmol/24 h). A random specimen usually contains more than 40 mEq/L of sodium. Urine sodium levels are used to assess volume status and are useful in the diagnosis of hyponatremia and acute renal failure.
HOMEOSTATIC MECHANISMS The body is equipped with remarkable homeostatic mechanisms to keep the composition and volume of body fluid within narrow limits of normal. Organs involved in homeostasis include the kidneys, lungs, heart, adrenal glands, parathyroid glands, and pituitary gland.
Kidney Functions Vital to the regulation of fluid and electrolyte balance, the kidneys normally filter 170 L of plasma every day in the adult, while excreting only 1.5 L of urine. They act both autonomously and in response to blood-borne messengers, such as aldosterone and antidiuretic hormone (ADH). Major functions of the kidneys in maintaining normal fluid balance include the following: • Regulation of ECF volume and osmolality by selective retention and excretion of body fluids • Regulation of electrolyte levels in the ECF by selective retention of needed substances and excretion of unneeded substances
254
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CONCEPTS AND CHALLENGES IN PATIENT MANAGEMENT
• Regulation of pH of the ECF by retention of hydrogen ions • Excretion of metabolic wastes and toxic substances Given these functions, it is readily apparent that renal failure will result in multiple fluid and electrolyte problems. Renal function declines with advanced age, as do muscle mass and daily exogenous creatinine production. Thus, high-normal and minimally elevated serum creatinine values may indicate substantially reduced renal function in the elderly.
Heart and Blood Vessel Functions The pumping action of the heart circulates blood through the kidneys under sufficient pressure to allow for urine formation. Failure of this pumping action interferes with renal perfusion and thus with water and electrolyte regulation.
Lung Functions The lungs are also vital in maintaining homeostasis. Through exhalation, the lungs remove approximately 300 mL of water daily in the normal adult. Abnormal conditions, such as hyperpnea (abnormally deep respiration) or continuous coughing, increase this loss; mechanical ventilation with excessive moisture decreases it. The lungs also have a major role in maintaining acid–base balance. Changes from normal aging result in decreased respiratory function, causing increased difficulty in pH regulation in older adults with major illness or trauma.
Pituitary Functions The hypothalamus manufactures ADH, which is stored in the posterior pituitary gland and released as needed. ADH is sometimes called the water-conserving hormone because it causes the body to retain water. Functions of ADH include maintaining the osmotic pressure of the cells by controlling the retention or excretion of water by the kidneys and by regulating blood volume (Fig. 14-2).
Adrenal Functions Aldosterone, a mineralocorticoid secreted by the zona glomerulosa (outer zone) of the adrenal cortex, has a profound effect on fluid balance. Increased secretion of aldosterone causes sodium retention (and thus water retention) and potassium loss. Conversely, decreased secretion of aldosterone causes sodium and water loss and potassium retention. Cortisol, another adrenocortical hormone, has only a fraction of the mineralocorticoid potency of aldosterone. When secreted in large quantities, however, it can also produce sodium and fluid retention and potassium deficit.
must be carefully maintained to ensure that tissues receive adequate nutrients. BARORECEPTORS The baroreceptors are small nerve receptors that detect changes in pressure within blood vessels and transmit this information to the central nervous system. They are responsible for monitoring the circulating volume, and they regulate sympathetic and parasympathetic neural activity as well as endocrine activities. They are categorized as low-pressure and high-pressure baroreceptor systems. Low-pressure baroreceptors are located in the cardiac atria, particularly the left atrium. The high-pressure baroreceptors are nerve endings in the aortic arch and in the cardiac sinus. Another high-pressure baroreceptor is located in the afferent arteriole of the juxtaglomerular apparatus of the nephron. As arterial pressure decreases, baroreceptors transmit fewer impulses from the carotid sinuses and the aortic arch to the vasomotor center. A decrease in impulses stimulates the sympathetic nervous system and inhibits the parasympathetic nervous system. The outcome is an increase in cardiac rate, conduction, and contractility and in circulating blood volume. Sympathetic stimulation constricts renal arterioles; this increases the release of aldosterone, decreases glomerular filtration, and increases sodium and water reabsorption. RENIN–ANGIOTENSIN–ALDOSTERONE SYSTEM Renin is an enzyme that converts angiotensinogen, an inactive substance formed by the liver, into angiotensin I. Renin is released by the juxtaglomerular cells of the kidneys in response to decreased renal perfusion. Angiotensin-converting enzyme (ACE) converts angiotensin I to angiotensin II. Angiotensin II, with its vasoconstrictor properties, increases arterial perfusion pressure and stimulates thirst. As the sympathetic nervous system is stimulated, aldosterone is released in response to an increased release of renin. Aldosterone is a volume regulator and is also released as serum potassium increases, serum sodium decreases, or adrenocorticotropic hormone increases. ADH AND THIRST ADH and the thirst mechanism have important roles in maintaining sodium concentration and oral intake of fluids. Oral intake is controlled by the thirst center located in the hypothalamus. As serum concentration or osmolality increases or blood volume decreases, neurons in the hypothalamus are stimulated by intracellular dehydration; thirst then occurs, and the person increases oral intake of fluids. Water excretion is controlled by ADH, aldosterone, and baroreceptors, as mentioned previously. The presence or absence of ADH is the most significant factor in determining whether the urine that is excreted is concentrated or dilute.
Other Mechanisms
OSMORECEPTORS Located on the surface of the hypothalamus, osmoreceptors sense changes in sodium concentration. As osmotic pressure increases, the neurons become dehydrated and quickly release impulses to the posterior pituitary, which increases the release of ADH. ADH travels in the blood to the kidneys, where it alters permeability to water, causing increased reabsorption of water and decreased urine output. The retained water dilutes the ECF and returns its concentration to normal. Restoration of normal osmotic pressure provides feedback to the osmoreceptors to inhibit further ADH release (see Fig. 14-2).
Changes in the volume of the interstitial compartment within the ECF can occur without affecting body function. The vascular compartment, however, cannot tolerate change as readily and
RELEASE OF ATRIAL NATRIURETIC PEPTIDE Atrial natriuretic peptide (ANP) is released by cardiac cells in the atria of the heart in response to increased atrial pressure. Any dis-
Parathyroid Functions The parathyroid glands, embedded in the thyroid gland, regulate calcium and phosphate balance by means of parathyroid hormone (PTH). PTH influences bone resorption, calcium absorption from the intestines, and calcium reabsorption from the renal tubules.
Chapter 14
Fluid and Electrolytes: Balance and Distribution
255
Physiology/Pathophysiology
Blood volume Serum osmolality s
e lat
u im
St
ADH production in hypothalamus (osmoreceptors)
( Thirst and water intake) ECF volume deficit
es at ul im St
Concentrated urine excreted
Arterial B/P (stimulates baroreceptors)
Sympathetic discharge
Inhibits
Renal perfusion Diuresis results H2 O and Na + filtered by kidney
Renin release ( GFR) (promotes peripheral vasoconstriction) ADH release into bloodstream from storage in posterior pituitary Angiotensin I and II
Aldosterone by adrenal cortex
Blood volume
Reabsorption of H2 O by distal tubule of kidneys
Serum osmolality Na+ and H2 O excretion by kidneys
Blood pressure
Urine excretion
Circulating volume of H 2O and Na +(loss of K +)
FIGURE 14-2
Fluid regulation cycle.
order that results in volume expansion or increased cardiac filling pressures (eg, high sodium intake, heart failure, chronic renal failure, atrial tachycardia, or use of vasoconstrictor agents) will increase the release of ANP. The action of ANP is the direct opposite of the renin–angiotensin–aldosterone system and decreases blood pressure and volume (Fig. 14-3). The ANP measured in plasma is normally 20 to 77 pg/mL (20—77 ng/L). This level increases in acute heart failure, paroxysmal atrial tachycardia, hyperthyroidism, subarachnoid hemorrhage, and small cell lung cancer.
The level decreases in chronic heart failure and with the use of medications such as urea (Ureaphil) and prazosin (Minipress). Gerontologic Considerations Normal physiologic changes of aging, including reduced renal and respiratory function and reserve and alterations in the ratio of body fluids to muscle mass, may alter the responses of an elderly person to fluid and electrolyte changes and acid–base disturbances. In
Unit 3
256
CONCEPTS AND CHALLENGES IN PATIENT MANAGEMENT
Physiology/Pathophysiology
Blood volume Blood pressure
Stretch of atria
in the elderly patient. These reactions are likely to occur more quickly and with the administration of smaller volumes of fluid than in healthy young and middle-aged adults because of the decreased cardiac reserve and reduced renal function that accompany aging. Increased sensitivity to fluid and electrolyte changes in the elderly patient requires careful assessment, with attention to intake and output of fluids from all sources and to changes in daily weight; careful monitoring of side effects and interactions of medications; and prompt reporting and management of disturbances. Additional gerontologic considerations relating to specific fluid and electrolyte disturbances are discussed later in this chapter.
Fluid Volume Disturbances FLUID VOLUME DEFICIT (HYPOVOLEMIA)
ANP release from cardiac cells in atria
Vascular resistance by causing vasodilation
Antidiuretic hormone release by posterior pituitary gland
Glomerular filtration rate which urinary excretion of sodium and water
Pathophysiology
Blood pressure Suppression of serum renin levels, inhibits action of angiotensin II, aldosterone release by adrenal glands
Vascular volume Blood pressure Preload and afterload
FIGURE 14-3
Fluid volume deficit (FVD) occurs when loss of extracellular fluid volume exceeds the intake of fluid. It occurs when water and electrolytes are lost in the same proportion as they exist in normal body fluids, so that the ratio of serum electrolytes to water remains the same. Fluid volume deficit (hypovolemia) should not be confused with the term dehydration, which refers to loss of water alone with increased serum sodium levels. FVD may occur alone or in combination with other imbalances. Unless other imbalances are present concurrently, serum electrolyte concentrations remain essentially unchanged.
Role of atrial natriuretic peptide (ANP) in maintenance of
fluid balance.
FVD results from loss of body fluids and occurs more rapidly when coupled with decreased fluid intake. FVD can develop from inadequate intake alone if the decreased intake is prolonged. Causes of FVD include abnormal fluid losses, such as those resulting from vomiting, diarrhea, GI suctioning, and sweating, and decreased intake, as in nausea or inability to gain access to fluids (Beck, 2000). Additional risk factors include diabetes insipidus, adrenal insufficiency, osmotic diuresis, hemorrhage, and coma. Third-space fluid shifts, or the movement of fluid from the vascular system to other body spaces (eg, with edema formation in burns or ascites with liver dysfunction), also produce FVD.
Clinical Manifestations addition, the frequent use of medications in older adults can affect renal and cardiac function and fluid balance, thereby increasing the likelihood of fluid and electrolyte disturbances. Routine procedures, such as the vigorous administration of laxatives before colon x-ray studies, may produce a serious fluid volume deficit, necessitating the use of intravenous (IV) fluids to prevent hypotension and other effects of hypovolemia. Alterations in fluid and electrolyte balance that may produce minor changes in young and middle-aged adults have the potential to produce profound changes in older adults, accompanied by a rapid onset of signs and symptoms. In other elderly patients, the clinical manifestations of fluid and electrolyte disturbances may be subtle or atypical. For example, fluid deficit or reduced sodium levels (hyponatremia) may cause confusion in the elderly person, whereas in young and middle-aged people the first sign commonly is increased thirst. Rapid infusion of an excessive volume of IV fluids may produce fluid overload and cardiac failure
FVD can develop rapidly and can be mild, moderate, or severe, depending on the degree of fluid loss. Important characteristics of FVD include acute weight loss; decreased skin turgor; oliguria; concentrated urine; postural hypotension; a weak, rapid heart rate; flattened neck veins; increased temperature; decreased central venous pressure; cool, clammy skin related to peripheral vasoconstriction; thirst; anorexia; nausea; lassitude; muscle weakness; and cramps.
Assessment and Diagnostic Findings Laboratory data useful in evaluating fluid volume status include BUN and its relation to the serum creatinine concentration. A volume-depleted patient has a BUN elevated out of proportion to the serum creatinine level (a ratio greater than 20:1). The cause of hypovolemia may be determined through the health history and physical examination. The BUN can be elevated due to dehydration or decreased renal perfusion and function. Also, the
Chapter 14 hematocrit level is greater than normal because the red blood cells become suspended in a decreased plasma volume. Serum electrolyte changes may also exist. Potassium and sodium levels can be reduced (hypokalemia, hyponatremia) or elevated (hyperkalemia, hypernatremia).
• • • •
Hypokalemia occurs with GI and renal losses. Hyperkalemia occurs with adrenal insufficiency. Hyponatremia occurs with increased thirst and ADH release. Hypernatremia results from increased insensible losses and diabetes insipidus.
Urine specific gravity is increased in relation to the kidneys’ attempt to conserve water and decreased with diabetes insipidus. Urine osmolality is greater than 450 mOsm/Kg, since the kidneys try to compensate by conserving water. Normal values for these tests are listed in Table 14-4. Gerontologic Considerations Elderly patients have special nursing care needs because of their propensity for developing fluid and electrolyte imbalances (Beck, 2000; Kugler & Hustead, 2000). Fluid balance in the elderly patient is often marginal at best because of certain physiologic changes associated with the aging process. Some of these changes include reduction in total body water (associated with increased body fat content and decreased muscle mass); reduction in renal function, resulting in decreased ability to concentrate urine; de-
Table 14-4
Fluid and Electrolytes: Balance and Distribution
creased cardiovascular and respiratory function; and disturbances in hormonal regulatory functions. Although these changes are viewed as normal in the aging process, they must be considered when the elderly person becomes ill because age-related changes predispose the person to fluid and electrolyte imbalances. These physiologic changes must be considered during assessment of the elderly patient as well as before initiating treatment for fluid and electrolyte imbalances. Assessment of the elderly patient should be modified somewhat from that of younger adults. For example, skin turgor is less valid in the assessment of elderly patients because their skin has lost some of its elasticity; therefore, other assessment measures (eg, slowness in filling of veins of the hands and feet) become more important in detecting FVD. In the elderly patient, skin turgor is best tested over the forehead or the sternum, because alterations in skin elasticity are less marked in these areas. As in any patient, skin turgor should be monitored serially to detect subtle changes. The nurse should perform a functional assessment of the aged person’s ability to determine fluid and food needs and to obtain adequate intake. For example, is the patient mentally clear? Is the patient able to ambulate and use both arms and hands to reach fluids and foods? Is the patient able to swallow? All of these questions have a direct bearing on how patients will be able to meet their own need for fluids and foods. During an elderly patient’s hospital stay, the nurse must provide fluids for any patient who is unable to carry out self-care activities.
• Laboratory Values Used In Evaluating Fluid and Electrolyte Status in Adults
TEST
USUAL REFERENCE RANGE
SI UNITS
Serum sodium Serum potassium Total serum calcium
135–145 mEq/L 3.5–5.3 mEq/L 8.6–10. mg/dL (approx. 50% in ionized form) 1.3–2.5 mEq/L 2.5–4.5 mg/dL 97–107 mEq/L 22–30 mEq/L 280–300 mOsm/kg H2O 5–20 mg/dL Females: 0.5–1.1 mg/dL Males: 0.6–1.2 mg/dL 10:1–15:1 Males: 42–52% Females: 35–47% 70–105 mg/dL 3.5–5.0 g/dL 75–220 mEq/day 25–123 mEq/day
135–145 mmol/L 3.5–5.3 mmol/L 2.15–2.5 mmol/L 0.65–1.25 mmol/L 0.87–1.45 mmol/L 97–107 mmol/L 22–30 mmol/L 280–300 mmol/kg H2O 1.8–7.1 mmol/L 44–97 mmol/L 53–105 mmol/L — Volume fraction: 0.42–0.52 Volume fraction: 0.35–0.47 3.9–5.8 mmol/L 3.5–5.0 g/L 75–220 mmol/day 25–123 mmol/day
110–250 mEq/24 h 1.016–1.022 250–900 mOsm/kg H2O Random: 4.5–8.0 Typical urine 108 mEq/L
Chloride deficit (hypochloremia) Serum chloride 7.4 (alkalosis) pH < 7.4 (acidosis) pH = 7.4 (normal) A normal pH may indicate perfectly normal blood gases, or it may be an indication of a compensated imbalance. A compensated imbalance is one in which the body has been able to correct the pH by either respiratory or metabolic changes (depending on the primary problem). For example, a patient with primary metabolic acidosis starts out with a low bicarbonate level but a normal CO2 level. Soon afterward, the lungs try to compensate for the imbalance by exhaling large amounts of CO2 (hyperventilation). As another example, a patient with primary respiratory acidosis starts out with a high CO2 level; soon afterward, the kidneys attempt to compensate by retaining bicarbonate. If the compensatory mechanism is able to restore the bicarbonate to carbonic acid ratio back to 20:1, full compensation (and thus normal pH) will be achieved. 2. The next step is to determine the primary cause of the distur− bance. This is done by evaluating the PaCO2 and HCO3 in relation to the pH. Example: pH > 7.4 (alkalosis) a. If the PaCO2 is < 40 mm Hg, the primary disturbance is respiratory alkalosis. (This situation occurs when a patient hyperventilates and “blows off” too much CO2. Recall that CO2 dissolved in water becomes carbonic acid, the acid side of the “carbonic acid–bicarbonate buffer system.”) − b. If the HCO3 is >24 mEq/L, the primary disturbance is metabolic alkalosis. (This situation occurs when the body gains too
much bicarbonate, an alkaline substance. Bicarbonate is the basic or alkaline side of the “carbonic acid–bicarbonate buffer system.”) Example: pH < 7.4 (acidosis) a. If the PaCO2 is >40 mm Hg, the primary disturbance is respiratory acidosis. (This situation occurs when a patient hypoventilates and thus retains too much CO2, an acidic substance.) − b. If the HCO3 is 500 mOsm/L); removal of blood specimens Single- and double-lumen catheters available (16–24 g) 7.5–20 cm in length. Can increase two gauges in size as it softens Silicone, polyurethane and their derivatives
Insertion sites
Catheter placement
Insertion method
Potential complications
Contraindications
Catheter maintenance
Through-the-needle technique, with or without a guidewire, breakaway needle with introducer or cannula with introducer (peelaway sheath). (A peripherally inserted central catheter can also be used as a midline catheter.) Insertion can be accomplished at the bedside using sterile technique. Arm to be used should be positioned in abduction to 90-degree angle. Consent is required. Catheter may stay in place for up to 12 months or as long as required without complications. Malposition, pneumothorax, hemothorax, hydrothorax, dysrhythmias, nerve or tendon damage, respiratory distress, catheter embolism, thrombophlebitis, or catheter occlusion. Compared with centrally placed catheters, venipuncture in the antecubital space reduces risk of insertion complications. Dermatitis, cellulitis, burns, high fluid volume infusions, rapid bolus injections, hemodialysis, and venous thrombosis. No clamping of this catheter or splinting of the arm permitted. No blood pressure or torniquets to be used on extremity where PICC is inserted. Sterile dressing changes according to agency policy and procedures. Generally, dressing is changed 2 or 3 ×/week or when wet, soiled, or nonocclusive. Line is flushed every 12 hours with 3 mL normal saline followed by heparin 3 mL (100 U/mL) per lumen.
Postplacement
Chest x-ray needed to confirm placement
Assessment
Daily measurement of arm circumference (4″ above insertion site) and length of exposed catheter Catheter should be removed when no longer indicated for use, if contaminated, or if complications occur. Arm is abducted during removal. Pressure is applied on removal with a sterile dressing and antiseptic ointment to site. Dressing is changed every 24 hours until epithelialization occurs. Reduces cost and avoids repeated venipunctures compared with centrally placed catheters. Decreases incidence of catheter-related infections.
Removal
Advantages
Venipuncture performed 2–3 fingerbreadths above the antecubital fossa or 1 fingerbreadth below the antecubital fossa into the cephalic, basilic, or median cubital vein Between the antecubital area and the head of the clavicle (tip in axilla region). The tip terminates in the proximal portion of the extremity below axilla and proximal to central veins and is advanced 3–10 inches. No separate guidewire or introducer is needed. Stiff catheter is passed using the catheter advancement tab. Insertion can be accomplished at the bedside using sterile technique. Arm to be used should be positioned in abduction to 45-degree angle. Consent is required. Catheter may stay in place for 2–4 weeks. Thrombosis, phlebitis, air embolism, infection, vascular perforation, bleeding, catheter transection, occlusion
Dermatitis, cellulitis, burns, high fluid volume infusions, rapid bolus injection, hemodialysis, and venous thrombosis. No blood pressure or torniquet to be used on extremity where midline catheter is placed. Sterile dressing changes according to policy and procedures. Generally the dressing should be changed 2 or 3 ×/week or when wet, soiled, or nonocclusive. Line is flushed after each infusion or every 12 hours with 5–10 mL normal saline followed by 1 mL of heparin (100 U/mL). Catheter must be anchored securely to prevent its dislodgment. Chest x-ray to assess placement may be obtained if unable to flush catheter, if no free flow blood return, if difficulty with catheter advancement, or if guidewire difficult to remove or bent on removal. Daily measurement of arm circumference (4″ above insertion site) and length of exposed catheter Catheter should be removed when no longer indicated for use, if contaminated, or if complications occur. Arm is abducted during removal. Pressure is applied on removal with a sterile dressing and antiseptic ointment to site. Dressing is changed every 24 hours until epithelialization occurs. Reduces cost and avoids repeated venipunctures compared with centrally placed catheters. Decreases incidence of catheter-related infections.
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Chart 14-2 GUIDELINES FOR Guidelines for Starting an Intravenous Infusion NURSING ACTION Preparation 1. Verify prescription for IV therapy, check solution label, and identify patient. 2. Explain procedure to patient. 3. Carry out hand hygiene and put on disposable nonlatex gloves. 4. Apply a tourniquet 4–6 inches above the site and identify a suitable vein. 5. Choose site. Use distal veins of hands and arms first.
6. Choose IV cannula or catheter. 7. Connect infusion bag and tubing, and run solution through tubing to displace air; cover end of tubing. 8. Raise bed to comfortable working height and position for patient; adjust lighting. Position patient’s arm below heart level to encourage capillary filling. Place protective pad on bed under patient’s arm. Procedure 1. Depending on agency policy and procedure, lidocaine 1% (without epinephrine) 0.1–0.2 mL may be injected locally to the IV site or a transdermal analgesic cream (EMLA) may be applied to the site 60 minutes before IV placement or blood withdrawal. Intradermal injection of bacteriostatic 0.9% sodium chloride may have a local anesthetic effect. 2. Question the patient carefully about sensitivity to latex; use blood-pressure cuff rather than latex tourniquet if there is possibility of sensitivity. 3. Apply a new tourniquet for each patient or a blood pressure cuff 15 to 20 cm (6–8 in) above injection site. Palpate for a pulse distal to the tourniquet. Ask patient to open and close fist several times or position patient’s arm in a dependent position to distend a vein.
4. Ascertain if the patient is allergic to iodine. Prepare site by scrubbing with chlorhexidine gluconate or povidone–iodine swabs for 2–3 min in circular motion, moving outward from injection site. Allow to dry. a. If the site selected is excessively hairy, clip hair. (Check agency’s policy and procedure about this practice.) b. 70% isopropyl alcohol is an alternative solution that may be used. 5. With hand not holding the venous access device, steady patient’s arm and use finger or thumb to pull skin taut over vessel. 6. Holding needle bevel up and at 5°–25° angle, depending on the depth of the vein, pierce skin to reach but not penetrate vein. 7. Decrease angle of needle further until nearly parallel with skin, then enter vein either directly above or from the side in one quick motion.
RATIONALE 1. Serious errors can be avoided by careful checking. 2. Knowledge increases patient comfort and cooperation. 3. Asepsis is essential to prevent infection. Prevents exposure of nurse to patient’s blood and of patient and nurse to latex. 4. This will distend the veins and allow them to be visualized. 5. Careful site selection will increase likelihood of successful venipuncture and preservation of vein. Using distal sites first preserves sites proximal to the previously cannulated site for subsequent venipunctures. Veins of feet and lower extremity should be avoided due to risk of thrombophlebitis. (In consultation with the physician, the saphenous vein of the ankle or dorsum of the foot may occasionally be used.) 6. Length and gauge of cannula should be appropriate for both site and purpose of infusion. The shortest gauge and length needed to deliver prescribed therapy should be used. 7. Prevents delay; equipment must be ready to connect immediately after successful venipuncture to prevent clotting 8. Proper positioning will increase likelihood of success and provide comfort for patient.
1. Reduces pain locally from procedure and decreases anxiety about pain
2. Reduces risk of allergic reaction 3. The tourniquet distends the vein and makes it easier to enter; it should never be tight enough to occlude arterial flow. If a radial pulse cannot be palpated distal to the tourniquet, it is too tight. A new tourniquet should be used for each patient to prevent the transmission of microorganisms. A blood pressure cuff may be used for elderly patients to avoid rupture of the veins. A clenched fist encourages the vein to become round and turgid. Positioning the arm below the level of the patient’s heart promotes capillary filling. Warm packs can promote vasodilation as well. 4. Strict asepsis and careful site preparation are essential to prevent infection.
5. Applying traction to the vein helps to stabilize it. 6. Bevel-up position usually produces less trauma to skin and vein. A superficial vein needs a smaller cannula angle and a vein deeper in subcutaneous tissue requires a greater cannula angle. 7. Two-stage procedure decreases chance of thrusting needle through posterior wall of vein as skin is entered. No attempt should be made to reinsert the stylet because of risk of severing or puncturing the catheter. (continued)
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Chart 14-2 GUIDELINES FOR Guidelines for Starting an Intravenous Infusion (Continued) NURSING ACTION 8. If backflow of blood is visible, straighten angle and advance needle. Additional steps for catheter inserted over needle: a. Advance needle 0.6 cm (1⁄4–1⁄2 in) after successful venipuncture. b. Hold needle hub, and slide catheter over the needle into the vein. Never reinsert needle into a plastic catheter or pull the catheter back into the needle. c. Remove needle while pressing lightly on the skin over the catheter tip; hold catheter hub in place. 9. Release tourniquet and attach infusion tubing; open clamp enough to allow drip.
10. Slip a sterile 2-in × 2-in gauze pad under the catheter hub. 11. Anchor needle firmly in place with tape. 12. Cover the insertion site with a transparent dressing, bandage, or sterile gauze; tape in place with nonallergenic tape but do not encircle extremity. 13. Tape a small loop of IV tubing onto dressing. 14. Cover the insertion site with a dressing according to hospital policy and procedure. A gauze or transparent dressing may be used. 15. Label dressing with type and length of cannula, date, time, and initials. 16. A padded, appropriate-length arm board may be applied to an area of flexion (neurovascular checks should be performed frequently). 17. Calculate infusion rate and regulate flow of infusion. For hourly IV rate use the following formula: gtt/mL of infusion set/60 (min in hr) × total hourly vol = gtt/min
18. Document site, cannula size and type, the number of attempts at insertion, time, solution, IV rate, and patient response to procedure.
uses a drop sensor to monitor the flow. Factors essential for the safe use of pumps include alarms to signify the presence of air in the IV line and occlusion. The standard for the accurate delivery of fluid or medication via an electronic IV infusion pump is plus or minus 5%. The manufacturer’s directions must be read carefully before using any infusion pump or controller, because there are many variations in available models. Use of these devices does not eliminate the need for the nurse to monitor the infusion and the patient frequently. DISCONTINUING AN INFUSION The removal of an IV catheter is associated with two possible dangers: bleeding and catheter embolism. To prevent excessive bleeding, a dry, sterile pressure dressing should be held over the site as the catheter is removed. Firm pressure is applied until hemostasis occurs. If a plastic IV catheter is severed, the loose fragment can travel to the right ventricle and block blood flow. To detect this com-
RATIONALE 8. Backflow may not occur if vein is small; this position decreases chance of puncturing posterior wall of vein. a. Advancing the needle slightly makes certain the plastic catheter has entered the vein. b. Reinsertion of the needle or pulling the catheter back can sever the catheter, causing catheter embolism. c. Slight pressure prevents bleeding before tubing is attached. 9. Infusion must be attached promptly to prevent clotting of blood in cannula. After two unsuccessful attempts at venipuncture, assistance by a more experienced health care provider is recommended to avoid unnecessary trauma to the patient and the possibility of limiting future sites for vascular access. 10. The gauze acts as a sterile field. 11. A stable needle is less likely to become dislodged or to irritate the vein. 12. Tape encircling extremity can act as a tourniquet. 13. The loop decreases the chance of inadvertent cannula removal if the tubing is pulled. 14. Transparent dressings allow assessment of the insertion site for phlebitis, infiltration, and infection without removing the dressing. 15. Labeling facilitates assessment and safe discontinuation. 16. Secures cannula placement and allows correct flow rate (neurovascular checks assess nerve, muscle, and vascular function to be sure function is not affected by immobilization) 17. Infusion must be regulated carefully to prevent overinfusion or underinfusion. Calculation of the IV rate is essential for the safe delivery of fluids. Safe administration requires knowledge of the volume of fluid to be infused, total infusion time, and the calibration of the administration set (found on the IV tubing package; 10, 12, 15, or 60 drops to deliver 1 mL of fluid). 18. Documentation is essential to promote continuity of care.
plication when the catheter is removed, the nurse compares the expected length of the catheter with its actual length. Plastic catheters should be withdrawn carefully and their length measured to make certain that no fragment has broken off. Great care must be exercised when using scissors around the dressing site. If the catheter clearly has been severed, the nurse can attempt to occlude the vein above the site by applying a tourniquet to prevent the catheter from entering the central circulation (until surgical removal is possible). As always, however, it is better to prevent a potentially fatal problem than to deal with it after it has occurred. Fortunately, catheter embolism can be prevented easily by following simple rules:
• Avoid using scissors near the catheter. • Avoid withdrawing the catheter through the insertion needle. • Follow the manufacturer’s guidelines carefully (eg, cover the
needle point with the bevel shield to prevent severance of the catheter).
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MANAGING SYSTEMIC COMPLICATIONS IV therapy predisposes the patient to numerous hazards, including both local and systemic complications. Systemic complications occur less frequently but are usually more serious than local complications. They include circulatory overload, air embolism, febrile reaction, and infection.
• Firmly anchoring the IV cannula to prevent to-and-fro
Fluid Overload. Overloading the circulatory system with excessive IV fluids causes increased blood pressure and central venous pressure. Signs and symptoms of fluid overload include moist crackles on auscultation of the lungs, edema, weight gain, dyspnea, and respirations that are shallow and have an increased rate. Possible causes include rapid infusion of an IV solution or hepatic, cardiac, or renal disease. The risk for fluid overload and subsequent pulmonary edema is especially increased in elderly patients with cardiac disease; this is referred to as circulatory overload. The treatment for circulatory overload is decreasing the IV rate, monitoring vital signs frequently, assessing breath sounds, and placing the patient in a high Fowler’s position. The physician is contacted immediately. This complication can be avoided by using an infusion pump for infusions and by carefully monitoring all infusions. Complications of circulatory overload include heart failure and pulmonary edema.
•
Air Embolism. The risk of air embolism is rare but ever-present. It is most often associated with cannulation of central veins. Manifestations of air embolism include dyspnea and cyanosis; hypotension; weak, rapid pulse; loss of consciousness; and chest, shoulder, and low back pain. Treatment calls for immediately clamping the cannula, placing the patient on the left side in the Trendelenburg position, assessing vital signs and breath sounds, and administering oxygen. Air embolism can be prevented by using a Luer-Lok adapter on all lines, filling all tubing completely with solution, and using an air detection alarm on an IV pump. Complications of air embolism include shock and death. The amount of air necessary to induce death in humans is not known; however, the rate of entry is probably as important as the actual volume of air.
•
Septicemia and Other Infection. Pyrogenic substances in either the infusion solution or the IV administration set can induce a febrile reaction and septicemia. Signs and symptoms include an abrupt temperature elevation shortly after the infusion is started, backache, headache, increased pulse and respiratory rate, nausea and vomiting, diarrhea, chills and shaking, and general malaise. In severe septicemia, vascular collapse and septic shock may occur. Causes of septicemia include contamination of the IV product or a break in aseptic technique, especially in immunocompromised patients. Treatment is symptomatic and includes culturing of the IV cannula, tubing, or solution if suspect and establishing a new IV site for medication or fluid administration. See Chapter 15 for a discussion of septic shock. Infection ranges in severity from local involvement of the insertion site to systemic dissemination of organisms through the bloodstream, as in septicemia. Measures to prevent infection are essential at the time the IV line is inserted and throughout the entire infusion. Prevention includes:
• Careful hand hygiene before every contact with any part of the infusion system or patient
• Examining the IV containers for cracks, leaks, or cloudiness, which may indicate a contaminated solution
• Using strict aseptic technique
motion
• Inspecting the IV site daily and replacing a soiled or wet
• • •
• • •
dressing with a dry sterile dressing. (Antimicrobial agents that should be used for site care include 2% tincture of iodine, 10% povidone–iodine, alcohol, or chlorhexidine, used alone or in combination.) Removing the IV cannula at the first sign of local inflammation, contamination, or complication Replacing the peripheral IV cannula every 48 to 72 hours, or as indicated Replacing the IV cannula inserted during emergency conditions (with questionable asepsis) as soon as possible Using a 0.2-micron air-eliminating and bacteria/particulate retentive filter with non-lipid-containing solutions that require filtration. The filter can be added to the proximal or distal end of the administration set. If added to the proximal end between the fluid container and the tubing spike, the filter ensures sterility and particulate removal from the infusate container and prevents inadvertent infusion of air. If added to the distal end of the administration set, it filters air particles and contaminants introduced from add-on devices, secondary administration sets, or interruptions to the primary system. Replacing the solution bag and administration set in accordance with agency policy and procedure Infusing or discarding medication or solution within 24 hours of its addition to an administration set Changing primary and secondary continuous administration sets every 72 hours, or immediately if contamination is suspected Changing primary intermittent administration sets every 24 hours, or immediately if contamination is suspected
MANAGING LOCAL COMPLICATIONS Local complications of IV therapy include infiltration and extravasation, phlebitis, thrombophlebitis, hematoma, and clotting of the needle. Infiltration and Extravasation. Infiltration is the unintentional administration of a nonvesicant solution or medication into surrounding tissue. This can occur when the IV cannula dislodges or perforates the wall of the vein. Infiltration is characterized by edema around the insertion site, leakage of IV fluid from the insertion site, discomfort and coolness in the area of infiltration, and a significant decrease in the flow rate. When the solution is particularly irritating, sloughing of tissue may result. Closely monitoring the insertion site is necessary to detect infiltration before it becomes severe. Infiltration is usually easily recognized if the insertion area is larger than the same site of the opposite extremity; however, it is not always so obvious. A common misconception is that a backflow of blood into the tubing proves that the catheter is properly placed within the vein. If the catheter tip has pierced the wall of the vessel, however, IV fluid will seep into tissues as well as flow into the vein. Although blood return occurs, infiltration has occurred as well. A more reliable means of confirming infiltration is to apply a tourniquet above (or proximal to) the infusion site and tighten it enough to restrict venous flow. If the infusion continues to drip despite the venous obstruction, infiltration is present. As soon as the nurse notes infiltration, the infusion should be stopped, the IV discontinued, and a sterile dressing applied to the
Chapter 14 site after careful inspection to determine the extent of infiltration. The infiltration of any amount of blood product, irritant, or vesicant is considered the most severe. The IV infusion should be started in a new site or proximal to the infiltration if the same extremity is used. A warm compress may be applied to the site if small volumes of noncaustic solutions have infiltrated over a long time, and the affected extremity should be elevated to promote the absorption of fluid. If the infiltration is recent, a cold compress may be applied to the area. Infiltration can be detected and treated early by inspecting the site every hour for redness, pain, edema, blood return, coolness at the site, and IV fluid draining from the IV site. Using the appropriate size and type of cannula for the vein prevents this complication. According to the Infusion Nursing Standards of Practice, a standardized infiltration scale should be used to document the infiltration (Alexander, 2000): 0 = No symptoms 1 = Skin blanched, edema less than 1 inch in any direction, cool to touch, with or without pain 2 = Skin blanched, edema 1 to 6 inches in any direction, cool to touch, with or without pain 3 = Skin blanched, translucent, gross edema greater than 6 inches in any direction, cool to touch, mild to moderate pain, possible numbness 4 = Skin blanched, translucent, skin tight, leaking, skin discolored, bruised, swollen, gross edema greater than 6 inches in any direction, deep pitting tissue edema, circulatory impairment, moderate to severe pain, infiltration of any amount of blood products, irritant, or vesicant Extravasation is similar to infiltration, with an inadvertent administration of vesicant or irritant solution or medication into the surrounding tissue. Medications such as dopamine, calcium preparations, and chemotherapeutic agents can cause pain, burning, and redness at the site. Blistering, inflammation, and necrosis of tissues can occur. The extent of tissue damage is determined by the concentration of the medication, the quantity that extravasated, the location of the infusion site, the tissue response, and the duration of the process of extravasation. The infusion must be stopped and the physician notified promptly. The agency’s protocol for extravasation is initiated; the protocol may specify specific treatments, including antidotes specific to the medication that extravasated, and may indicate whether the IV line should remain in place or be removed before treatment. The protocol often specifies that the infusion site be infiltrated with an antidote prescribed after assessment by the physician and application of warm or cold compresses, depending on the medication infusing. This extremity should not be used for further cannula placement. Thorough neurovascular assessments of the affected extremity must be performed frequently. Reviewing the institution’s IV policy and procedures and incompatibility charts and checking with the pharmacist before administering any IV medication, whether given peripherally or centrally, is a prudent way to determine incompatibilities and vesicant potential to prevent extravasation. Careful, frequent monitoring of the IV site, avoiding insertion of IV devices in areas of flexion, securing the IV line, and using the smallest catheter possible that accommodates the vein help minimize the incidence and severity of this complication. In addition, when vesicant medication is administered by IV push, it should be given through a side port of an infusing IV solution to dilute the medication and decrease the severity of tissue damage if extravasation oc-
Fluid and Electrolytes: Balance and Distribution
291
curs. Extravasation should always be rated as a grade 4 on the infiltration scale. Phlebitis. Phlebitis is defined as inflammation of a vein related to a chemical or mechanical irritation, or both. It is characterized by a reddened, warm area around the insertion site or along the path of the vein, pain or tenderness at the site or along the vein, and swelling. The incidence of phlebitis increases with the length of time the IV line is in place, the composition of the fluid or medication infused (especially its pH and tonicity), the size and site of the cannula inserted, ineffective filtration, improper anchoring of the line, and the introduction of microorganisms at the time of insertion. The Intravenous Nursing Society has identified specific standards for assessing phlebitis (Alexander, 2000); these appear in Chart 14-3. Treatment consists of discontinuing the IV and restarting it in another site, and applying a warm, moist compress to the affected site. Phlebitis can be prevented by using aseptic technique during insertion, using the appropriate-size cannula or needle for the vein, considering the composition of fluids and medications when selecting a site, observing the site hourly for any complications, anchoring the cannula or needle well, and changing the IV site according to agency policy and procedures. Thrombophlebitis. Thrombophlebitis refers to the presence of a clot plus inflammation in the vein. It is evidenced by localized pain, redness, warmth, and swelling around the insertion site or along the path of the vein, immobility of the extremity because of discomfort and swelling, sluggish flow rate, fever, malaise, and leukocytosis. Treatment includes discontinuing the IV infusion, applying a cold compress first to decrease the flow of blood and increase platelet aggregation followed by a warm compress, elevating the extremity, and restarting the line in the opposite extremity. If the patient has signs and symptoms of thrombophlebitis, the IV line should not be flushed (although flushing may be indicated in
Chart 14-3
• ASSESSMENT
Phlebitis According to the Infusion Nurses Society, documentation of phlebitis should be standardized. Phlebitis should be graded according to the most severe presenting indication Grade
0 1 2 3
4
Clinical Criteria
No clinical symptoms Erythema at access site with or without pain Pain at access site Erythema, edema, or both Pain at access site Erythema, edema, or both Streak formation Palpable venous cord (1 in. or shorter) Pain at access site with erythema Streak formation Palpable venous cord (longer than 1 in.) Purulent drainage
Note: If this scale is not being used in an institution, then the description associated with the number can be used to describe the assessment. From Infusion Nursing Standards of Practice (2000). Journal of Intravenous Nursing, 23(6S), S56–S69.
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the absence of phlebitis to ensure cannula patency and to prevent mixing incompatible medications and solutions). Thrombophlebitis can be prevented by avoiding trauma to the vein at the time the IV is inserted, observing the site every hour, and checking medication additives for compatibility. Hematoma. Hematoma results when blood leaks into tissues surrounding the IV insertion site. Leakage can result from perforation of the opposite vein wall during venipuncture, the needle slipping out of the vein, and insufficient pressure applied to the site after removing the needle or cannula. The signs of a hematoma include ecchymosis, immediate swelling at the site, and leakage of blood at the site. Treatment includes removing the needle or cannula and applying pressure with a sterile dressing; applying ice for 24 hours to the site to avoid extension of the hematoma and then a warm compress to increase absorption of blood; assessing the site; and restarting the line in the other extremity if indicated. A hematoma can be prevented by carefully inserting the needle and using diligent care when a patient has a bleeding disorder, takes anticoagulant medication, or has advanced liver disease. Clotting and Obstruction. Blood clots may form in the IV line as a result of kinked IV tubing, a very slow infusion rate, an empty IV bag, or failure to flush the IV line after intermittent medication or solution administrations. The signs are decreased flow rate and blood backflow into the IV tubing. If blood clots in the IV line, the infusion must be discontinued and restarted in another site with a new cannula and administration set. The tubing should not be irrigated or milked. Neither the infusion rate nor the solution container should be raised, and the clot should not be aspirated from the tubing. Clotting of the needle or cannula may be prevented by not permitting the IV solution bag to run dry, taping the tubing to prevent kinking and maintain patency, maintaining an adequate flow rate, and flushing the line after intermittent medication or other solution administration. In some cases, a specially trained nurse or physician may inject a thrombolytic agent into the catheter to clear an occlusion resulting from fibrin or clotted blood. PROMOTING HOME AND COMMUNITY-BASED CARE Teaching Patients Self-Care. At times, IV therapy must be administered in the home setting, in which case much of the daily management rests with the patient and family. Teaching becomes essential to ensure that the patient and family can manage the IV fluid and infusion properly and avoid complications. Written instructions as well as demonstration and return demonstration help reinforce the key points for all these functions. Continuing Care. Home infusion therapies cover a wide range of treatments, including antibiotic, analgesic, and antineoplastic medications; blood or blood component therapy; and parenteral nutrition. When direct nursing care is necessary, arrangements can be made to have an infusion nurse visit the home and administer the IV therapy as prescribed. In addition to implementing and monitoring the IV therapy, the nurse carries out a comprehensive assessment of the patient’s condition and continues to teach the patient and family about the skills involved in overseeing the IV therapy setup. Any dietary changes that may be necessary because of fluid or electrolyte imbalances are explained or reinforced during such sessions. Periodic laboratory testing may be necessary to assess the effects of IV therapy and the patient’s progress. Blood specimens may be
obtained by a laboratory near the patient’s home, or a home visit may be arranged to obtain blood specimens for analysis. The nurse collaborates with the case manager in assessing the patient, family, and home environment; developing a plan of care in accordance with the patient’s treatment plan and level of ability; and arranging for appropriate referral and follow-up if necessary. Any necessary equipment may be provided by the agency or purchased by the patient, depending on the terms of the home care arrangements. Appropriate documentation is necessary to assist in obtaining third-party payment for the service provided.
?
Critical Thinking Exercises
1.
A 40-year-old man with peptic ulcer disease reports vomiting, nausea, dry mucous membranes, and abdominal pain for the last 2 days. His BP is 92/64 and pulse is 120. His laboratory results show a serum sodium level of 125 mEq/L, urine sodium level of 5 mEq/L, and measured serum osmolality of 270 mOsm/L. What IV solution do you anticipate will be prescribed for him? Provide a rationale for its use, and discuss the nursing actions relevant to its administration.
2.
A 30-year-old woman comes into the emergency department with a temperature of 39.4°C (103°F). For the last 4 days she has had a productive cough and has experienced dyspnea increasing in severity. Her serum laboratory results are as follows: WBC = 20,000, pH = 7.59, PaCO2 = 26, PaO2 = 40, SaO2 = 80, HCO3 = 20, Na+ = 140, K+ = 4.2, Cl− = 106, CO2 = 20. What is the acid–base disorder? What treatments and relevant nursing actions related to the underlying disorder and its treatment should the nurse anticipate?
3.
A 48-year-old woman reports shortness of breath that has been increasing in the last 3 months so much so that she is no longer able to use her treadmill. She is a nonsmoker. Her chest x-ray is negative. She does not take any medications. Her arterial blood gases are as follows: pH = 7.41, PaCO2 = 37 mm Hg, PaO2 = 94 mm Hg, HCO3 = 23 mmHg, pulse oximetry = 98%. What is your interpretation of her blood gas values? What action is indicated by these results?
4.
An obtunded 84-year-old man is admitted to the hospital from the nursing home with a high fever. The following clinical data are obtained on admission: temperature 39.4°C (102°F); BP 150/90; pulse rate of 110; dry, mucous membranes. Laboratory test results include the following: serum Na+ = 184 mEq/L, urine osmolality = 640 mOsm/kg; urine culture and sensitivity shows pyuria and many bacteria. His peripheral IV at the site of the right dorsal metacarpal vein is infiltrated. What method of administering IV fluids would the nurse anticipate? What factors are probably contributing to his hypernatremia? What nursing actions should be taken in assisting with treatment of this patient’s fluid and electrolyte imbalance?
5.
A 65-year-old patient with severe, long-standing COPD is admitted to the hospital for treatment of impending renal failure. Explain the effects of his pulmonary disorder on the acid– base disturbances that commonly occur with renal failure. What are the nursing observations and assessment that are indicated because of the occurrence of these two disorders?
Chapter 14 REFERENCES AND SELECTED READINGS Books Chernecky, C. C., & Berger, B. J. (2001) Laboratory tests and diagnostic procedures (3d ed.). Philadelphia: W. B. Saunders. Guyton, A. C. (2000). Textbook of medical physiology (10th ed.). Philadelphia: W. B. Saunders. Hankins, J., Lonsway-Waldman, R., Hedrick, C., & Perdue, M. B. (2001). Infusion therapy in clinical practice (2d ed.). Philadelphia: W. B. Saunders. Heitz, U., & Horne, M. (2001). Pocket guide to fluid, electrolyte, and acid-base balance (4th ed.). St. Louis: Mosby. Karch, A. M. (2002). Lippincott’s nursing drug guide. Philadelphia: Lippincott Williams & Wilkins. Kee, J., & Paulanka, B. (2000). Handbook of fluid, electrolyte and acidbase imbalances. Albany, NY: Delmar Publishers. Martin, L. (1999). All you need to know to interpret arterial blood gases (2d ed.). Philadelphia: Lippincott Williams & Wilkins. Metheny, N. M. (2000). Fluid and electrolyte balance: Nursing considerations (4th ed.). Philadelphia: Lippincott Williams & Wilkins. Otto, S. E. (2001). Pocket guide to intravenous therapy (4th ed.). St. Louis: C. V. Mosby. Porth, C. M. (2002). Pathophysiology: Concepts of altered health states (6th ed.). Philadelphia: Lippincott Williams & Wilkins. Price, S. A., & Wilson, L. M. (2003). Pathophysiology. Clinical concepts of disease processes. St. Louis: Mosby–Year Book. Rose, B., & Post, T. (2001). Clinical physiology of acid–base and electrolyte disorders (5th ed.). New York: McGraw-Hill. Weinstein, S. (2001). Plumer’s principles and practice of intravenous therapy. Philadelphia: Lippincott Williams & Wilkins.
Journals Asterisks indicate nursing research articles. Fluid and Electrolyte Balances Adrogue, H. J., & Madias, N. E. (2000a). Hyponatremia. New England Journal of Medicine, 342(21), 1581–1589. Adrogue, H. J., & Madias, N. E. (2000b). Hypernatremia. New England Journal of Medicine, 342(20),1493–1499. Anonymous. (2000). Part 1: Introduction to the International Guidelines 2000 for CPR and ECC: A consensus on science. Circulation, 102(8 Suppl), I1–I11. Beck, L. H. (2000). The aging kidney. Defending a delicate balance of fluid and electrolytes. Geriatrics, 55(4), 26–28, 31–32. Brater, D. C. (1998). Diuretic therapy. New England Journal of Medicine, 339(6), 387–395. Carlstedt, F., & Lind, L. (2001). Hypocalcemic syndromes. Critical Care Clinics, 17(1), 139–153, vii–viii. Castiglione, V. (2000). Emergency: Hyperkalemia. American Journal of Nursing, 100(1), 55–56. Clayton, K. (1997). Cancer-related hypercalcemia: How to spot it, how to manage it. American Journal of Nursing, 97(5), 42–49. Cohn, J. N., Kowey, P. R., Whelton, P. K., & Prisant, L. M. (2000). New guidelines for potassium replacement in clinical practice: A contemporary review by the National Council on Potassium in Clinical Practice. Archives of Internal Medicine, 160(16), 2429–2436. Fall, P. J. (2000). Hyponatremia and hypernatremia. A systematic approach to causes and their correction. Postgraduate Medicine, 107(5), 75–82. Fulop, M. (1998). Algorithms for diagnosing some electrolyte disorders. American Journal of Emergency Medicine, 16(1), 76–84. Gross, P. (2001). Correction of hyponatremia. Seminars in Nephrology, 21(3), 269–272. Gennari, F. J. (1998). Hypokalemia. New England Journal of Medicine, 339(7), 451–458. Goldhill, D. R. (1997). Calcium and magnesium. Care of the Critically Ill, 13(3), 112–115. Kreimeier, U. (2000). Pathophysiology of fluid imbalance. Critical Care (London), 4, Suppl 2:S3–S7.
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Kugler, J. P., & Hustead, T. (2000). Hyponatremia and hypernatremia in the elderly. American Family Physician, 61(12), 3623–3630. Lee, C. T., Guo, H. R., & Chen, J. B. (2000). Hyponatremia in the emergency department. American Journal of Emergency Medicine, 18(3), 264–268. Lilly, L. L., & Guanci, R. (1997). Persistent potassium problems. American Journal of Nursing, 97(6), 14. Marx, S. J. (2000). Hyperparathyroid and hypoparathyroid disorders. New England Journal of Medicine, 343(25), 1863–1875. Nayback, A. M. (2000). Hyponatremia as a consequence of acute adrenal insufficiency and hypothyroidism. Journal of Emergency Nursing, 26(2), 130–133. Oster, J. R., & Singer, I. (1999). Hyponatremia, hypoosmolality, and hypotonicity. Archives of Internal Medicine, 159(4), 333–336. Perazella, M. A. (2000). Drug-induced hyperkalemia: Old culprits and new offenders. American Journal of Medicine, 109(4), 307–314. Pirzada, N. A., & Ali, I. I. (2001). Central pontine myelinolysis. Mayo Clinic Proceedings, 76(5), 559–562. *Rateau, M. R. (2000). Confusion and aggression in restrained elderly persons undergoing hip repair surgery. Applied Nursing Research, 13(1), 50–54. Schmidt, T. C. (2000). Assessing a sodium and fluid imbalance. Nursing, 30(1), 18. Suhayda, R. & Walton, J. C. (2002). Preventing and managing dehydration. MedSurg Nursing, 11(6), 267–278. Terpstra, T. L., & Terpstra, T. L. (2000). Syndrome of inappropriate antidiuretic hormone: Recognition and management. MedSurg Nursing, 9(2). 61–68. Toto, K. H. (1998). Fluid balance assessment. Critical Care Nursing Clinics of North America, 10(4), 383–400. Wilcox, C. S. (1999). Metabolic and adverse effects of diuretics. Seminars in Nephrology, 19(6), 557–568. Acid–Base Balance Adrogue, H. E., & Adrogue, H. J. (2001). Acid-base physiology. Respiratory Care, 46(4), 328–341. Epstein, S. K., & Singh, N. (2001). Respiratory acidosis. Respiratory Care, 46(4), 366–383. Foster, G. T., Vaziri, N. D., & Sassoon, C. S. (2001). Respiratory alkalosis. Respiratory Care, 46(4), 384–391. Horne, C., & Derrico, D. (1999). Mastering the art of arterial blood gas measurement. American Journal of Nursing, 99(8), 26–32. Khanna, A., & Kurtzman, N. A. (2001). Metabolic alkalosis. Respiratory Care, 46(4), 354–365. Kraut, J. A., & Madias, N. E. (2001). Approach to patients with acidbase disorders. Respiratory Care, 46(4), 392–403. Sassoon, C. S., & Arruda, J. A. (2001). Acid-base disturbance. Respiratory Care, 46(4), 327. Shoulders-Odom, B. (2000). Using an algorithm to interpret arterial blood gases. Dimensions of Critical Care Nursing, 19(1), 36–41. Swenson, E. R. (2001). Metabolic acidosis. Respiratory Care, 46(4), 342–353. Wallace, L. S. (2000). Using color to simplify ABG interpretation. MedSurg Nursing, 9(4), 205–207. Williams, A. (1998). ABC of oxygen. Assessing and interpreting arterial blood gases and acid-base balance. British Medical Journal, 317(7167), 1213–1216. Wong, F. W. H. (1999). A new approach to ABG interpretation. American Journal of Nursing, 99(8), 26–32. Intravenous Administration Alexander, M. (2000). Infusion Nursing Standards of Practice. Journal of Intravenous Nursing, 23(6), Suppl. S5–S88. Andrews, C. M. (2002). Emergency: Preventing air embolism. American Journal of Nursing, 102(1), 34–36. Andris, D. A., & Jrzywda, E. A. (1999). Central venous catheter occlusion: Successful management strategies. MedSurg Nursing, 8(4), 229–236. Aschenbrenner, D. A. (2000). Skin preps and protocols. American Journal of Nursing, 100(4), 78.
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Carlson, K. (1999). Correct utilization and management of peripherally inserted central catheters and midline catheters in the alternate care setting. Journal of Intravenous Nursing, 22(6), Suppl. S46–S50. Driscoll, M., et al. (1997). Inserting and maintaining peripherally inserted central catheters. MedSurg Nursing, 6(6), 350–358. *Fetzer, S. J. (2002). Reducing venipuncture and intravenous insertion pain with eutectic mixture of local anesthetic. A meta-analysis. Nursing Research, 51(2), 119–124. *Fry, C. & Aholt, D. (2001). Local anesthesia prior to the insertion of peripherally inserted central catheters. Journal of Infusion Nursing, 24(6), 404 – 408. Hadaway, L. C. (1999). Vascular access devices: Meeting patients’ needs. MedSurg Nursing, 8(5), 296–303. Intravenous Nurses Society. (1997). Position paper: Midline and midclavicular catheters. Journal of Intravenous Nursing, 20(4), 175–178. Intravenous Nurses Society. (1997). Position paper: Peripherally inserted central catheters. Journal of Intravenous Nursing, 20(4), 172–174.
Krzywda, E. A. (1998). Central venous access—catheters, technology, and physiology. MedSurg Nursing, 7(3), 132–139. Kupensky, D. (1998). Applying current research to influence clinical practice. Journal of Intravenous Nursing, 21(5), 271–274. LeDuc, K. (1997) Efficacy of normal saline solution versus heparin solution for maintaining patency of peripheral intravenous catheters in children. Journal of Emergency Nursing, 23(4), 306–309. Macklin, D. (2000). Removing a PICC. American Journal of Nursing, 100(1), 52–54. Millam, D. (2000). On the road to successful venipuncture. Nursing, 30(4), 34–48. Moureau, N., & Zonderman, A. (2000) Does it always have to hurt? Premedications for adults and children for use with intravenous therapy. Journal of Intravenous Nursing, 23(4), 213–219.
RESOURCES AND WEBSITES Infusion Nurses Society, 220 Norwood Park South, Norwood, MA 02062; (781) 440-9408; http://www.ins1.org.
Chapter
15 ●
Shock and Multisystem Failure
LEARNING OBJECTIVES
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On completion of this chapter, the learner will be able to: 1. Describe shock and its underlying pathophysiology. 2. Compare clinical findings of the compensatory and progressive 3. 4. 5. 6. 7. 8. 9.
stages of shock. Describe organ damage that may occur with shock. Compare hypovolemic, cardiogenic, and circulatory shock in terms of causes, pathophysiologic effects, and medical and nursing management. Describe indications for varying types of fluid replacement. Identify vasoactive medications used in treating shock, and describe nursing implications associated with their use. Discuss the importance of nutritional support in all forms of shock. Discuss the role of the nurse in psychosocial support of both the patient experiencing shock and the family. Discuss the syndrome of multiple organ dysfunction.
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hock is a life-threatening condition with a variety of underlying causes. It is characterized by inadequate tissue perfusion that, if untreated, results in cell death. The nurse caring for the patient with shock or at risk for shock must understand the underlying mechanisms of shock and recognize its subtle as well as more obvious signs. Rapid assessment and response are essential to the patient’s recovery. Shock can best be defined as a condition in which systemic blood pressure is inadequate to deliver oxygen and nutrients to support vital organs and cellular function (Mikhail, 1999). Adequate blood flow to the tissues and cells requires the following components: adequate cardiac pump, effective vasculature or circulatory system, and sufficient blood volume. When one component is impaired, blood flow to the tissues is threatened or compromised. Without treatment, inadequate blood flow to the tissues results in poor delivery of oxygen and nutrients to the cells, cellular starvation, cell death, organ dysfunction progressing to organ failure, and eventual death.
Significance of Shock Shock affects all body systems. It may develop rapidly or slowly, depending on the underlying cause. During shock, the body struggles to survive, calling on all its homeostatic mechanisms to restore blood flow and tissue perfusion. Any insult to the body can create a cascade of events resulting in poor tissue perfusion. Therefore, almost any patient with any disease state may be at risk for developing shock. Nursing care of the patient with shock requires ongoing systematic assessment. Many of the interventions required in caring for the patient with shock call for close collaboration with other members of the health care team and a physician’s orders. The nurse must anticipate such orders because they need to be executed with speed and accuracy.
Conditions Precipitating Shock CLASSIFICATION OF SHOCK Shock can be classified by etiology and may be described as (1) hypovolemic shock, (2) cardiogenic shock, or (3) circulatory or distributive shock. Some authors identify a fourth category, obstructive shock, that results from disorders that cause mechanical obstruction to blood flow through the central circulatory system despite normal myocardial function and intravascular volume.
Examples include pulmonary embolism, cardiac tamponade, dissecting aortic aneurysm, and tension pneumothorax. In this discussion, obstructive disorders are discussed as examples of noncoronary cardiogenic shock. Hypovolemic shock occurs when there is a decrease in the intravascular volume. Cardiogenic shock occurs when the heart has an impaired pumping ability; it may be of coronary or noncoronary origin. Circulatory shock results from a maldistribution or mismatch of blood flow to the cells.
NORMAL CELLULAR FUNCTION Energy metabolism occurs within the cell, where nutrients are chemically broken down and stored in the form of adenosine triphosphate (ATP). Cells use this stored energy to perform necessary functions, such as active transport, muscle contraction, and biochemical synthesis, as well as specialized cellular functions, such as the conduction of electrical impulses. ATP can be synthesized aerobically (in the presence of oxygen) or anaerobically (in the absence of oxygen). Aerobic metabolism yields far greater amounts of ATP per mole of glucose than does anaerobic metabolism and, therefore, is a more efficient and effective means of producing energy. Additionally, anaerobic metabolism results in the accumulation of the toxic end product lactic acid, which must be removed from the cell and transported to the liver for conversion into glucose and glycogen.
PATHOPHYSIOLOGY In shock, the cells lack an adequate blood supply and are deprived of oxygen and nutrients; therefore, they must produce energy through anaerobic metabolism. This results in low energy yields from nutrients and an acidotic intracellular environment. Because of these changes, normal cell function ceases (Fig. 15-1). The cell swells and the cell membrane becomes more permeable, allowing electrolytes and fluids to seep out of and into the cell. The sodium-potassium pump becomes impaired; cell structures, primarily the mitochondria, are damaged; and death of the cell results.
Vascular Responses Oxygen attaches to the hemoglobin molecule in red blood cells, and the blood carries it to body cells. The amount of oxygen that is delivered to cells depends both on blood flow to a specific area and on blood oxygen concentration. Blood is continuously re-
Glossary anaphylactic shock: circulatory shock state resulting from a severe allergic reaction producing an overwhelming systemic vasodilation and relative hypovolemia biochemical mediators: messenger substances that may be released by a cell to create an action at that site or be carried by the bloodstream to a distant site before being activated; also called cytokines cardiogenic shock: shock state resulting from impairment or failure of the myocardium
colloids: intravenous solutions that contain molecules that are too large to pass through capillary membranes crystalloids: electrolyte solutions that move freely between the intravascular compartment and interstitial spaces circulatory shock: shock state resulting from displacement of blood volume creating a relative hypovolemia and inadequate delivery of oxygen to the cells; also called distributive shock hypovolemic shock: shock state resulting from decreased intravascular volume due to fluid loss
neurogenic shock: shock state resulting from loss of sympathetic tone causing relative hypovolemia septic shock: circulatory shock state resulting from overwhelming infection causing relative hypovolemia shock: physiologic state in which there is inadequate blood flow to tissues and cells of the body systemic inflammatory response syndrome (SIRS): overwhelming inflammatory response in the absence of infection causing relative hypovolemia and decreased tissue perfusion
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Cellular edema Efflux of K+
Increased membrane permeability Lysosomal membrane rupture Influx of Na+ and H2O
Cell damage and death
Mitochondrial damage (swelling)
Normal Effects of shock
FIGURE 15-1
Cellular effects of shock. The cell swells and the cell membrane becomes more permeable, and fluids and electrolytes seep from and into the cell. Mitochondria and lysosomes are damaged, and the cell dies.
cycled through the lungs to be reoxygenated and to eliminate end products of cellular metabolism, such as carbon dioxide. The heart muscle is the pump that propels the freshly oxygenated blood out to the body tissues. This process of circulation is facilitated through an elaborate and dynamic vasculature consisting of arteries, arterioles, capillaries, veins, and venules. The vasculature can dilate or constrict based on central and local regulatory mechanisms. Central regulatory mechanisms stimulate dilation or constriction of the vasculature to maintain an adequate blood pressure. Local regulatory mechanisms, referred to as autoregulation, stimulate vasodilation or vasoconstriction in response to biochemical mediators (also called cytokines) released by the cell, communicating its need for oxygen and nutrients (Jindal, Hollenberg & Dellinger, 2000) A biochemical mediator is a substance released by a cell or immune cells such as polymorphonuclear leukocytes (PMNs) or macrophages; the substance triggers an action at a cell site or travels in the bloodstream to a distant site, where it triggers action.
Blood Pressure Regulation Three major components of the circulatory system—blood volume, the cardiac pump, and the vasculature—must respond effectively to complex neural, chemical, and hormonal feedback systems to maintain an adequate blood pressure and ultimately perfuse body tissues. Blood pressure is regulated through a complex interaction of neural, chemical, and hormonal feedback systems affecting both cardiac output and peripheral resistance. This relationship is expressed in the following equation: Mean arterial blood pressure = cardiac output × peripheral resistance
Cardiac output is determined by stroke volume (the amount of blood ejected at systole) and heart rate. Peripheral resistance is determined by the diameter of the arterioles.
Tissue perfusion and organ perfusion depend on mean arterial pressure (MAP). The MAP is the average pressure at which blood moves through the vasculature. Although true MAP can be calculated only by complex methods, Chart 15-1 displays a convenient formula for clinical use in estimating MAP. MAP should exceed 70 to 80 mm Hg for cells to receive the oxygen and nutrients needed to metabolize energy in amounts sufficient to sustain life (Balk, 2000a). Blood pressure is regulated by the baroreceptors (pressure receptors) located in the carotid sinus and aortic arch. These pressure receptors convey impulses to the sympathetic nervous center in the medulla of the brain. When blood pressure drops, catecholamines (epinephrine and norepinephrine) are released from the adrenal medulla of the adrenal glands. This increases heart rate and vasoconstriction, thus restoring blood pressure. Chemoreceptors, also located in the aortic arch and carotid arteries, regulate blood pressure and respiratory rate using much the same mechanism in response to changes in oxygen and carbon dioxide concentrations in the blood. These primary regulatory mechanisms can respond to changes in blood pressure on a moment-to-moment basis.
Chart 15-1 MAP =
Formula for Estimating Mean Arterial Pressure (MAP) systolic BP + 2(diastolic BP) 3
Example: patient’s BP = 125/75 mm Hg
MAP =
125 + (2 × 75) 3
MAP = 92 (rounded to nearest 1/10)
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The kidneys also play an important role in blood pressure regulation. They regulate blood pressure by releasing renin, an enzyme needed for the conversion of angiotensin I to angiotensin II, a potent vasoconstrictor. This stimulation of the renin-angiotensin mechanism and resulting vasoconstriction indirectly lead to the release of aldosterone from the adrenal cortex, which promotes the retention of sodium and water. The increased concentration of sodium in the blood then stimulates the release of antidiuretic hormone (ADH) by the pituitary gland. ADH causes the kidneys to retain water further in an effort to raise blood volume and blood pressure. These secondary regulatory mechanisms may take hours or days to respond to changes in blood pressure. To summarize, adequate blood volume, an effective cardiac pump, and an effective vasculature are necessary to maintain blood pressure and tissue perfusion. When one of the three components of this system begins to fail, the body is able to compensate through increased work by the other two (Fig. 15-2). When
compensatory mechanisms can no longer compensate for the failed system, body tissues are inadequately perfused, and shock occurs. Without prompt intervention, shock progresses, resulting in organ dysfunction, organ failure, and death.
Stages of Shock Some think of the shock syndrome as a continuum along which the patient struggles to survive. A convenient way to understand the physiologic responses and subsequent clinical signs and symptoms is to divide the continuum into separate stages: compensatory, progressive, and irreversible. (Although some authorities identify an initial stage of shock, changes attributed to this stage occur at the cellular level and are generally not detectable clinically.) The earlier that medical management and nursing interventions can be initiated along this continuum, the greater the patient’s chance of survival.
Physiology/Pathophysiology
FIGURE 15-2 Compensatory mechanisms for the restoration of circulatory blood volume in shock. Adapted with permission from Jones, K. (1996). Shock. In J. M. Clochesy, C. Breu, et al. (Eds.). Critical care nursing (2nd ed.). Philadelphia: W. B. Saunders Company.
Chapter 15 COMPENSATORY STAGE In the compensatory stage of shock, the patient’s blood pressure remains within normal limits. Vasoconstriction, increased heart rate, and increased contractility of the heart contribute to maintaining adequate cardiac output. This results from stimulation of the sympathetic nervous system and subsequent release of catecholamines (epinephrine and norepinephrine). The patient displays the often-described “fight or flight” response. The body shunts blood from organs such as the skin, kidneys, and gastrointestinal tract to the brain and heart to ensure adequate blood supply to these vital organs. As a result, the patient’s skin is cold and clammy, bowel sounds are hypoactive, and urine output decreases in response to the release of aldosterone and ADH.
Clinical Manifestations Despite a normal blood pressure, the patient shows numerous clinical signs indicating inadequate organ perfusion (Chart 15-2). The result of inadequate perfusion is anaerobic metabolism and a buildup of lactic acid, producing metabolic acidosis. The respiratory rate increases in response to metabolic acidosis. This rapid respiratory rate facilitates removal of excess carbon dioxide but raises the blood pH and often causes a compensatory respiratory alkalosis. The alkalotic state causes mental status changes, such as confusion or combativeness, as well as arteriolar dilation. If treatment begins in this stage of shock, the prognosis for the patient is good.
Medical Management Medical treatment is directed toward identifying the cause of the shock, correcting the underlying disorder so that shock does not progress, and supporting those physiologic processes that thus far have responded successfully to the threat. Because compensation cannot be effectively maintained indefinitely, measures such as fluid replacement and medication therapy must be initiated to maintain an adequate blood pressure and reestablish and maintain adequate tissue perfusion.
Nursing Management Early intervention along the continuum of shock is the key to improving the patient’s prognosis. Therefore, the nurse needs to assess systematically those patients at risk for shock to recognize the subtle clinical signs of the compensatory stage before the patient’s blood pressure drops.
Chart 15-2
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MONITORING TISSUE PERFUSION In assessing tissue perfusion, the nurse observes for changes in level of consciousness, vital signs (including pulse pressure), urinary output, skin, and laboratory values. In the compensatory stage of shock, serum sodium and blood glucose levels are elevated in response to the release of aldosterone and catecholamines. The role of the nurse at the compensatory stage of shock is to monitor the patient’s hemodynamic status and promptly report deviations to the physician, assist in identifying and treating the underlying disorder by continuous in-depth assessment of the patient, administer prescribed fluids and medications, and promote patient safety. Vital signs are key indicators of the patient’s hemodynamic status; however, blood pressure is an indirect method of monitoring tissue hypoxia. Pulse pressure correlates well to stroke volume, the amount of blood ejected from the heart with systole. Pulse pressure is calculated by subtracting the diastolic measurement from the systolic measurement; the difference is the pulse pressure. Normally, the pulse pressure is 30 to 40 mm Hg (Mikhail, 1999). Narrowing or decreased pulse pressure is an earlier indicator of shock than a drop in systolic blood pressure. Decreased or narrowing pulse pressure, an early indication of decreased stroke volume, is illustrated in the following example: Systolic blood pressure − diastolic blood pressure = pulse pressure
Normal pulse pressure: Systolic BP Diastolic BP 120 mg Hg − 80 mm Hg = Narrowing of pulse pressure: Systolic BP Diastolic BP 90 mm Hg − 70 mm Hg =
Pulse Pressure 40 mm Hg Pulse Pressure 20 mm Hg
Elevation in the diastolic blood pressure with release of catecholamines and attempts to increase venous return through vasoconstriction is an early compensatory mechanism in response to decreased stroke volume, blood pressure, and overall cardiac output.
!
NURSING ALERT By the time blood pressure drops, damage has already been occurring on the cellular and tissue levels. Therefore, the patient at risk for shock must be assessed and monitored closely before the blood pressure falls.
Although treatments are prescribed and initiated by the physician, the nurse usually implements them, operates and troubleshoots equipment used in treatment, monitors the patient’s status during treatment, and assesses the immediate effects of treatment. Additionally, the nurse assesses the response of the patient and the family to the crisis and to treatment.
• ASSESSMENT
Clinical Findings in Stages of Shock Finding
Compensatory
Progressive
Irreversible
Blood pressure Heart rate Respiratory status Skin Urinary output Mentation Acid–base balance
Normal >100 bpm >20 breaths/min Cold, clammy Decreased Confusion Respiratory alkalosis
Systolic 150 bpm Rapid, shallow respirations; crackles Mottled, petechiae 0.5 mL/kg/hr Lethargy Metabolic acidosis
Requires mechanical or pharmacologic support Erratic or asystole Requires intubation Jaundice Anuric, requires dialysis Unconscious Profound acidosis
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REDUCING ANXIETY While experiencing a major threat to health and well-being and being the focus of attention of many health care providers, the patient often becomes anxious and apprehensive. Providing brief explanations about the diagnostic and treatment procedures, supporting the patient during those procedures, and providing information about their outcomes are usually effective in reducing stress and anxiety and thus promoting the patient’s physical and mental well-being.
subsequently collapse. Pulmonary capillaries begin to leak their contents, causing pulmonary edema, diffusion abnormalities (shunting), and additional alveolar collapse. Interstitial inflammation and fibrosis are common as the pulmonary damage progresses (Fein & Calalang-Colucci, 2000). This condition is sometimes referred to as acute respiratory distress syndrome (ARDS), acute lung injury (ALI), shock lung, or noncardiogenic pulmonary edema. Further explanation of ARDS, as well as its nursing management, can be found in Chapter 23.
PROMOTING SAFETY Another nursing intervention is monitoring potential threats to the patient’s safety, because a high anxiety level and altered mental status typically impair a person’s judgment. In this stage, patients who were previously cooperative and followed instructions may now disrupt intravenous lines and catheters and complicate their condition. Therefore, close monitoring is essential.
CARDIOVASCULAR EFFECTS A lack of adequate blood supply leads to dysrhythmias and ischemia. The patient has a rapid heart rate, sometimes exceeding 150 bpm. The patient may complain of chest pain and even suffer a myocardial infarction. Cardiac enzyme levels (eg, lactate dehydrogenase, CPK-MB, and cTn-I) rise. In addition, myocardial depression and ventricular dilation may further impair the heart’s ability to pump enough blood to the tissues to meet oxygen requirements.
PROGRESSIVE STAGE In the progressive stage of shock, the mechanisms that regulate blood pressure can no longer compensate and the MAP falls below normal limits, with an average systolic blood pressure of less than 90 mm Hg (Abraham et al., 2000).
Pathophysiology Although all organ systems suffer from hypoperfusion at this stage, two events perpetuate the shock syndrome. First, the overworked heart becomes dysfunctional; the body’s inability to meet increased oxygen requirements produces ischemia; and biochemical mediators cause myocardial depression (Kumar, Haery & Parrillo, 2000; Price, Anning, Mitchell et al., 1999). This leads to failure of the cardiac pump, even if the underlying cause of the shock is not of cardiac origin. Second, the autoregulatory function of the microcirculation fails in response to numerous biochemical mediators released by the cells, resulting in increased capillary permeability, with areas of arteriolar and venous constriction further compromising cellular perfusion. At this stage, the patient’s prognosis worsens. The relaxation of precapillary sphincters causes fluid to leak from the capillaries, creating interstitial edema and return of less fluid to the heart. Even if the underlying cause of the shock is reversed, the breakdown of the circulatory system itself perpetuates the shock state, and a vicious circle ensues.
Assessment and Diagnostic Findings Chances of survival depend on the patient’s general health before the shock state as well as the amount of time it takes to restore tissue perfusion. As shock progresses, organ systems decompensate. RESPIRATORY EFFECTS The lungs, which become compromised early in shock, are affected at this stage. Subsequent decompensation of the lungs increases the likelihood that mechanical ventilation will be needed if shock progresses. Respirations are rapid and shallow. Crackles are heard over the lung fields. Decreased pulmonary blood flow causes arterial oxygen levels to decrease and carbon dioxide levels to increase. Hypoxemia and biochemical mediators cause an intense inflammatory response and pulmonary vasoconstriction, perpetuating the pulmonary capillary hypoperfusion and hypoxemia. The hypoperfused alveoli stop producing surfactant and
NEUROLOGIC EFFECTS As blood flow to the brain becomes impaired, the patient’s mental status deteriorates. Changes in mental status occur as a result of decreased cerebral perfusion and hypoxia; the patient may initially exhibit confusion or a subtle change in behavior. Subsequently, lethargy increases and the patient begins to lose consciousness. The pupils dilate and are only sluggishly reactive to light. RENAL EFFECTS When the MAP falls below 80 mm Hg (Guyton & Hall, 2000), the glomerular filtration rate of the kidneys cannot be maintained, and drastic changes in renal function occur. Acute renal failure (ARF) can develop. ARF is characterized by an increase in blood urea nitrogen (BUN) and serum creatinine levels, fluid and electrolyte shifts, acid–base imbalances, and a loss of the renalhormonal regulation of blood pressure. Urinary output usually decreases to below 0.5/mL/kg per hour (or below 30 mL per hour) but can be variable depending on the phase of ARF. For further information about ARF, see Chapter 45. HEPATIC EFFECTS Decreased blood flow to the liver impairs the liver cells’ ability to perform metabolic and phagocytic functions. Consequently, the patient is less able to metabolize medications and metabolic waste products, such as ammonia and lactic acid. The patient becomes more susceptible to infection as the liver fails to filter bacteria from the blood. Liver enzymes (aspartate aminotransferase [AST], formerly serum glutamic-oxaloacetic transaminase [SGOT]; alanine aminotransferase [ALT], formerly serum glutamate pyruvate transaminase [SGPT]; lactate dehydrogenase) and bilirubin levels are elevated, and the patient appears jaundiced. GASTROINTESTINAL EFFECTS Gastrointestinal ischemia can cause stress ulcers in the stomach, placing the patient at risk for gastrointestinal bleeding. In the small intestine, the mucosa can become necrotic and slough off, causing bloody diarrhea. Beyond the local effects of impaired perfusion, gastrointestinal ischemia leads to bacterial toxin translocation, in which bacterial toxins enter the bloodstream through the lymph system. In addition to causing infection, bacterial toxins can cause cardiac depression, vasodilation, increased capillary permeability, and an intense inflammatory response with activa-
Chapter 15 tion of additional biochemical mediators. The net result is interference with healthy cells and their ability to metabolize nutrients (Balk, 2000b; Jindal et al., 2000). HEMATOLOGIC EFFECTS The combination of hypotension, sluggish blood flow, metabolic acidosis, and generalized hypoxemia can interfere with normal hemostatic mechanisms. Disseminated intravascular coagulation (DIC) can occur either as a cause or as a complication of shock. In this condition, widespread clotting and bleeding occur simultaneously. Bruises (ecchymoses) and bleeding (petechiae) may appear in the skin. Coagulation times (prothrombin time, partial thromboplastin time) are prolonged. Clotting factors and platelets are consumed and require replacement therapy to achieve hemostasis. Further discussion of disseminated intravascular coagulation appears in Chapter 33.
Medical Management Specific medical management in the progressive stage of shock depends on the type of shock and its underlying cause. It is also based on the degree of decompensation in the organ systems. Medical management specific to each type of shock is discussed in later sections of this chapter. Although there are several differences in medical management by type of shock, some medical interventions are common to all types. These include use of appropriate intravenous fluids and medications to restore tissue perfusion by (1) optimizing intravascular volume, (2) supporting the pumping action of the heart, and (3) improving the competence of the vascular system. Other aspects of management may include early enteral nutritional support and use of antacids, histamine-2 blockers, or antipeptic agents to reduce the risk of gastrointestinal ulceration and bleeding.
Nursing Management Nursing care of the patient in the progressive stage of shock requires expertise in assessing and understanding shock and the significance of changes in assessment data. The patient in the progressive stage of shock is often cared for in the intensive care setting to facilitate close monitoring (hemodynamic monitoring, electrocardiographic monitoring, arterial blood gases, serum electrolyte levels, physical and mental status changes), rapid and frequent administration of various prescribed medications and fluids, and possibly intervention with supportive technologies, such as mechanical ventilation, dialysis, and intra-aortic balloon pump. Working closely with other members of the health care team, the nurse carefully documents treatments, medications, and fluids that are administered by members of the team, recording the time, dosage or volume, and the patient’s response. Additionally, the nurse coordinates both the scheduling of diagnostic procedures that may be carried out at the bedside and the flow of health care personnel involved in the patient’s care. PREVENTING COMPLICATIONS If supportive technologies are used, the nurse helps reduce the risk of related complications and monitors the patient for early signs of complications. Monitoring includes evaluating blood levels of medications, observing invasive vascular lines for signs of infection, and checking neurovascular status if arterial lines are inserted, especially in the lower extremities. Simultaneously, the nurse promotes the patient’s safety and comfort by ensuring that
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all procedures, including invasive procedures and arterial and venous punctures, are carried out using correct aseptic techniques and that venous and arterial puncture and infusion sites are maintained with the goal of preventing infection. Positioning and repositioning the patient to promote comfort, prevent pulmonary complications, and maintain skin integrity are integral to caring for the patient in shock. PROMOTING REST AND COMFORT Efforts are made to minimize the cardiac workload by reducing the patient’s physical activity and fear or anxiety. Promoting rest and comfort is a priority in the patient’s care. To ensure that the patient gets as much uninterrupted rest as possible, the nurse performs only essential nursing activities. To conserve the patient’s energy, the nurse protects the patient from temperature extremes (excessive warmth or shivering cold), which can increase the metabolic rate and subsequently the cardiac workload. The patient should not be warmed too quickly, and warming blankets should not be applied because they can cause vasodilation and a subsequent drop in blood pressure. SUPPORTING FAMILY MEMBERS Because the patient in shock is the object of intense attention by the health care team, the family members may feel neglected; however, they may be reluctant to ask questions or seek information for fear that they will be in the way or will interfere with the attention given to the patient. The nurse should make sure that the family is comfortably situated and kept informed about the patient’s status. Often, family members need advice from the health care team to get some rest; they are more likely to take this advice if they feel that the patient is being well cared for and that they will be notified of any significant changes in the patient’s status. A visit from the hospital chaplain may be comforting to the family and provides some attention to the family while the nurse concentrates on the patient.
IRREVERSIBLE STAGE The irreversible (or refractory) stage of shock represents the point along the shock continuum at which organ damage is so severe that the patient does not respond to treatment and cannot survive. Despite treatment, blood pressure remains low. Complete renal and liver failure, compounded by the release of necrotic tissue toxins, creates an overwhelming metabolic acidosis. Anaerobic metabolism contributes to a worsening lactic acidosis. Reserves of ATP are almost totally depleted, and mechanisms for storing new supplies of energy have been destroyed. Multiple organ dysfunction progressing to complete organ failure has occurred, and death is imminent. Multiple organ dysfunction can occur as a progression along the shock continuum or as a syndrome unto itself and is further described later in this chapter.
Medical Management Medical management during the irreversible stage of shock is usually the same as for the progressive stage. Although the patient’s condition may have progressed from the progressive to the irreversible stage, the judgment that the shock is irreversible can be made only retrospectively on the basis of the patient’s failure to respond to treatment. Strategies that may be experimental (ie, investigational medications, such as antibiotic agents and immunomodulation therapy) may be tried to reduce or reverse the severity of shock.
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Nursing Management
Crystalloid and Colloid Solutions
As in the progressive stage of shock, the nurse focuses on carrying out prescribed treatments, monitoring the patient, preventing complications, protecting the patient from injury, and providing comfort. Offering brief explanations to the patient about what is happening is essential even if there is no certainty that the patient hears or understands what is being said. As it becomes obvious that the patient is unlikely to survive, the family needs to be informed about the prognosis and likely outcomes. Opportunities should be provided, throughout the patient’s care, for the family to see, touch, and talk to the patient. A close family friend or spiritual advisor may be of comfort to the family in dealing with the inevitable death of the patient. Whenever possible and appropriate, the family should be approached regarding any living will, advance directive, or other written or verbal wishes the patient may have shared in the event that he or she cannot participate in end-of-life decisions. In some cases, ethics committees may assist the family and health care team in making difficult decisions. During this stage of shock, families may misinterpret the actions of the health care team. They have been told that nothing has been effective in reversing the shock and that the patient’s survival is very unlikely, yet the health care team continues to work feverishly on the patient. A distraught, grieving family may interpret this as a chance for recovery when none exists. As a result, family members may become angry when the patient dies. Conferences with all members of the health care team and the family will promote better understanding by the family of the patient’s prognosis and the purpose for the measures being taken. During these conferences, it is essential to explain that the equipment and treatments being provided are for the patient’s comfort and do not suggest that the patient will recover. Families should be encouraged to express their wishes concerning the use of life-support measures.
The best fluid to treat shock remains controversial. In emergencies, the “best” fluid is often the fluid that is readily available. Both crystalloids and colloids, as described later, can be given to restore intravascular volume. Blood component therapy is used most frequently in hypovolemic shock. Crystalloids are electrolyte solutions that move freely between the intravascular compartment and the interstitial spaces. Isotonic crystalloid solutions are often selected because they contain the same concentration of electrolytes as the extracellular fluid and therefore can be given without altering the concentrations of electrolytes in the plasma. Common intravenous fluids used for resuscitation in hypovolemic shock include 0.9% sodium chloride solution (normal saline) and lactated Ringer’s solution (Choi et al., 1999). Ringer’s lactate is an electrolyte solution containing the lactate ion, which should not be confused with lactic acid. The lactate ion is converted to bicarbonate, which helps to buffer the overall acidosis that occurs in shock. A disadvantage of using isotonic crystalloid solutions is that three parts of the volume are lost to the interstitial compartment for every one part that remains in the intravascular compartment. This occurs in response to mechanisms that store extracellular body fluid. Diffusion of crystalloids into the interstitial space necessitates that more fluid be administered than the amount lost (Choi et al., 1999). Care must be taken when rapidly administering isotonic crystalloids to avoid causing excessive edema, particularly pulmonary edema. For this reason, and depending on the cause of the hypovolemia, a hypertonic crystalloid solution, such as 3% sodium chloride, is sometimes administered in hypovolemic shock. Hypertonic solutions produce a large osmotic force that pulls fluid from the intracellular space to the extracellular space to achieve a fluid balance (Choi et al., 1999; Fein & CalalangColucci, 2000). The osmotic effect of hypertonic solutions results in fewer fluids being administered to restore intravascular volume. Complications associated with use of hypertonic saline solution include excessive serum osmolality, hypernatremia, hypokalemia, and altered thermoregulation. Generally, intravenous colloidal solutions are considered to be plasma proteins, which are molecules that are too large to pass through capillary membranes. Colloids expand intravascular volume by exerting oncotic pressure, thereby pulling fluid into the intravascular space. Colloidal solutions have the same effect as hypertonic solutions in increasing intravascular volume, but less volume of fluid is required than with crystalloids. Additionally, colloids have a longer duration of action than crystalloids because the molecules remain within the intravascular compartment longer. An albumin solution is commonly used to treat hypovolemic shock. Albumin is a plasma protein; an albumin solution is prepared from human plasma and is heated to reduce its potential to transmit disease. The disadvantages of albumin are its high cost and limited availability, which depends on blood donors. Synthetic colloid preparations, such as hetastarch and dextran solution, are now widely used. Dextran, however, may interfere with platelet aggregation and therefore is not indicated if hemorrhage is the cause of the hypovolemic shock or if the patient has a coagulation disorder (coagulopathy).
Overall Management Strategies in Shock As described previously and in the discussion of types of shock to follow, management in all types and all phases of shock includes the following:
• Fluid replacement to restore intravascular volume • Vasoactive medications to restore vasomotor tone and improve cardiac function
• Nutritional support to address the metabolic requirements that are often dramatically increased in shock
Therapies described in this section require collaboration among all members of the health care team to ensure that the manifestations of shock are quickly identified and that adequate and timely treatment is instituted to achieve the best outcome possible.
FLUID REPLACEMENT Fluid replacement is administered in all types of shock. The type of fluids administered and the speed of delivery vary, but fluids are given to improve cardiac and tissue oxygenation, which in part depends on flow. The fluids administered may include crystalloids (electrolyte solutions that move freely between intravascular and interstitial spaces), colloids (large-molecule intravenous solutions), or blood components.
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NURSING ALERT With all colloidal solutions, side effects include the rare occurrence of anaphylactic reactions, for which the nurse must monitor the patient closely.
Chapter 15 Complications of Fluid Administration Close monitoring of the patient during fluid replacement is necessary to identify side effects and complications. The most common and serious side effects of fluid replacement are cardiovascular overload and pulmonary edema. Patients receiving fluid replacement must be monitored frequently for adequate urinary output, changes in mental status, skin perfusion, and changes in vital signs. Lung sounds are auscultated frequently to detect signs of fluid accumulation. Adventitious lung sounds, such as crackles, may indicate pulmonary edema. Often a right atrial pressure line (also known as a central venous pressure line) is inserted. In addition to physical assessment, the right atrial pressure value helps in monitoring the patient’s response to fluid replacement. A normal right atrial pressure value is 4 to 12 mm Hg or cm H2O. Several readings are obtained to determine a range, and fluid replacement is continued to achieve a pressure within normal limits. Hemodynamic monitoring with arterial and pulmonary artery lines may be implemented to allow close monitoring of the patient’s perfusion and cardiac status as well as response to therapy.
VASOACTIVE MEDICATION THERAPY Vasoactive medications are administered in all forms of shock to improve the patient’s hemodynamic stability when fluid therapy alone cannot maintain adequate MAP. Specific medications are selected to correct the particular hemodynamic alteration that is impeding cardiac output. Specific vasoactive medications are prescribed for the patient in shock because they can support the patient’s hemodynamic status. These medications help to increase the strength of myocardial contractility, regulate the heart rate, reduce myocardial resistance, and initiate vasoconstriction. Vasoactive medications are selected for their action on receptors of the sympathetic nervous system. These receptors are known as alpha-adrenergic and beta-adrenergic receptors. Beta-adrenergic receptors are further classified as beta1- and beta2-adrenergic receptors. When alpha-adrenergic receptors are stimulated, blood vessels constrict in the cardiorespiratory and gastrointestinal systems, skin, and kidneys. When beta1-adrenergic receptors are stimulated, heart rate and myocardial contraction increase. When
Table 15-1
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beta2-adrenergic receptors are stimulated, vasodilation occurs in the heart and skeletal muscles, and the bronchioles relax. The medications used in treating shock consist of various combinations of vasoactive medications to maximize tissue perfusion by stimulating or blocking the alpha- and beta-adrenergic receptors. When vasoactive medications are administered, vital signs must be monitored frequently (at least every 15 minutes until stable, or more often if indicated). Vasoactive medications should be administered through a central venous line because infiltration and extravasation of some vasoactive medications can cause tissue necrosis and sloughing. An intravenous pump or controller should be used to ensure that the medications are delivered safely and accurately. Individual medication dosages are usually titrated by the nurse, who adjusts the intravenous drip rates based on the physician’s prescription and the patient’s response. Dosages are changed to maintain the MAP (usually above 80 mm Hg) at a physiologic level that ensures adequate tissue perfusion.
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NURSING ALERT Vasoactive medications should never be stopped abruptly because this could cause severe hemodynamic instability, perpetuating the shock state.
Dosages of vasoactive medications should be tapered and the patient should be weaned from the medication with frequent monitoring (every 15 minutes) of blood pressure. Table 15-1 presents some of the commonly prescribed vasoactive medications used in treating shock.
NUTRITIONAL SUPPORT Nutritional support is an important aspect of care for the patient with shock. Increased metabolic rates during shock increase energy requirements and therefore caloric requirements. The patient in shock requires more than 3,000 calories daily. The release of catecholamines early in the shock continuum causes glycogen stores to be depleted in about 8 to 10 hours. Nutritional energy requirements are then met by breaking down lean body mass. In this catabolic process, skeletal muscle mass is broken down even when the patient has large stores of fat or adipose tissue. Loss of skeletal muscle can greatly prolong the recovery
• Vasoactive Agents Used in Treating Shock
MEDICATION
DESIRED ACTION IN SHOCK
DISADVANTAGES
Sympathomimetics Amrinone (Inocor) Dobutamine (Dobutrex) Dopamine (Intropin) Epinephrine (Adrenalin) Milrinone (Primacor) Vasodilators Nitrogylcerine (Tridil) Nitroprusside (Nipride) Vasoconstrictors Norepinephrine (Levophed) Phenylephrine (Neo-Synephrine) Vasopressin (Pitressin)
Improve contractility, increase stroke volume, increase cardiac output
Increase oxygen demand of the heart
Reduce preload and afterload, reduce oxygen demand of heart
Cause hypotension
Increase blood pressure by vasoconstriction
Increase afterload, thereby increasing cardiac workload; compromise perfusion to skin, kidneys, lungs, GI tract
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time for the patient in shock. Parenteral or enteral nutritional support should be initiated as soon as possible, with some form of enteral nutrition always being administered. The integrity of the gastrointestinal system depends on direct exposure to nutrients. Additionally, glutamine (an essential amino acid during stress) is important in the immunologic function of the gastrointestinal tract, providing a fuel source for lymphocytes and macrophages. Glutamine can be administered through enteral nutrition (Rauen & Munro, 1998). Stress ulcers occur frequently in acutely ill patients because of the compromised blood supply to the gastrointestinal tract. Therefore, antacids, histamine-2 blockers (eg, famotidine [Pepcid], ranitidine [Zantac]), and antipeptic agents (eg, sucralfate [Carafate]) are prescribed to prevent ulcer formation by inhibiting gastric acid secretion or increasing gastric pH.
Physiology/Pathophysiology
Decreased blood volume
Decreased venous return
Decreased stroke volume
Hypovolemic Shock In addition to caring for the patient through different stages of shock, the nurse needs to tailor interventions to the type of shock, whether it is hypovolemic, cardiogenic, or circulatory shock. Hypovolemic shock, the most common type of shock, is characterized by a decreased intravascular volume. Body fluid is contained in the intracellular and extracellular compartments. Intracellular fluid accounts for about two thirds of the total body water. The extracellular body fluid is found in one of two compartments: intravascular (inside blood vessels) or interstitial (surrounding tissues). The volume of interstitial fluid is about three to four times that of intravascular fluid. Hypovolemic shock occurs when there is a reduction in intravascular volume of 15% to 25%. This would represent a loss of 750 to 1,300 mL of blood in a 70-kg (154-lb) person.
Pathophysiology Hypovolemic shock can be caused by external fluid losses, such as traumatic blood loss, or by internal fluid shifts, as in severe dehydration, severe edema, or ascites (Chart 15-3). Intravascular volume can be reduced both by fluid loss and fluid shifting between the intravascular and interstitial compartments. The sequence of events in hypovolemic shock begins with a decrease in the intravascular volume. This results in decreased venous return of blood to the heart and subsequent decreased ventricular filling. Decreased ventricular filling results in decreased stroke volume (amount of blood ejected from the heart) and decreased cardiac output. When cardiac output drops, blood pressure drops and tissues cannot be adequately perfused (Fig. 15-3).
Chart 15-3
Risk Factors for Hypovolemic Shock External: Fluid Losses Trauma Surgery Vomiting Diarrhea Diuresis Diabetes insipidus
Internal: Fluid Shifts Hemorrhage Burns Ascites Peritonitis Dehydration
Decreased cardiac output
Decreased tissue perfusion
FIGURE 15-3
Pathophysiologic sequence of events in hypovolemic shock.
Medical Management Major goals in treating hypovolemic shock are to (1) restore intravascular volume to reverse the sequence of events leading to inadequate tissue perfusion, (2) redistribute fluid volume, and (3) correct the underlying cause of the fluid loss as quickly as possible. Depending on the severity of shock and the patient’s condition, it is likely that efforts will be made to address all three goals simultaneously. TREATMENT OF THE UNDERLYING CAUSE If the patient is hemorrhaging, efforts are made to stop the bleeding. This may involve applying pressure to the bleeding site or surgery to stop internal bleeding. If the cause of the hypovolemia is diarrhea or vomiting, medications to treat diarrhea and vomiting are administered as efforts are made simultaneously to identify and treat the cause. In the elderly patient, dehydration may be the cause of hypovolemic shock. FLUID AND BLOOD REPLACEMENT Beyond reversing the primary cause of the decreased intravascular volume, fluid replacement (also referred to as fluid resuscitation) is of primary concern. At least two large-gauge intravenous lines are inserted to establish access for fluid administration. Two intravenous lines allow simultaneous administration of fluid, medications, and blood component therapy if required. Because the goal of the fluid replacement is to restore intravascular volume, it is necessary to administer fluids that will remain in the intravascular compartment and thus avoid creating fluid shifts from the intravascular compartment into the intracellular compartment. Table 15-2 summarizes the fluids commonly used in treating shock.
Chapter 15
Table 15-2
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• Fluid Replacement in Shock
FLUIDS
ADVANTAGES
DISADVANTAGES
Crystalloids 0.9% sodium chloride (normal saline solution)
Widely available, inexpensive
Lactated Ringer’s
Lactate ion helps buffer metabolic acidosis
Hypertonic saline (3%, 5%, 7.5%)
Small volume needed to restore intravascular volume
Requires large volume of infusion; can cause pulmonary edema Requires large volume of infusion; can cause pulmonary edema Danger of hypernatremia
Colloids Albumin (5%, 25%)
Rapidly expands plasma volume
Dextran (40, 70)
Synthetic plasma expander
Hetastarch
Synthetic; less expensive than albumin; effect lasts up to 36 h
Lactated Ringer’s and 0.9% sodium chloride solutions are isotonic crystalloid fluids commonly used in treating hypovolemic shock (Jindal et al., 2000). Large amounts of fluid must be administered to restore intravascular volume because isotonic crystalloid solutions move freely between the fluid compartments of the body and do not remain in the vascular system. Colloids (eg, albumin, hetastarch, and dextran) may also be used. Dextran is not indicated if the cause of the hypovolemic shock is hemorrhage because it interferes with platelet aggregation. Blood products, also colloids, may need to be administered, particularly when the cause of the hypovolemic shock is hemorrhage. Because of the risk of transmitting bloodborne viruses and the scarcity of blood products, however, these products are used only if other alternatives are unavailable or blood loss is extensive and rapid. Packed red blood cells are administered to replenish the patient’s oxygen-carrying capacity in conjunction with other fluids that will expand volume. Current recommendations are to base the need for transfusions on the patient’s oxygenation needs, which are determined by vital signs, blood gas values, and clinical appearance rather than using an arbitrary laboratory value. Synthetic forms of blood (ie, compounds capable of carrying oxygen in the same way that blood does) are potential alternatives.
Expensive; requires human donors; limited supply; can cause heart failure Interferes with platelet aggregation; not recommended for hemorrhagic shock Prolongs bleeding and clotting times
secondary to hyperglycemia; desmopressin (DDAVP) is administered for diabetes insipidus, antidiarrheal agents for diarrhea, and antiemetic medications for vomiting.
Nursing Management Primary prevention of shock is an essential focus of nursing intervention. Hypovolemic shock can be prevented in some instances by closely monitoring patients who are at risk for fluid deficits and assisting with fluid replacement before intravascular volume is depleted. In other circumstances, hypovolemic shock cannot be prevented, and nursing care focuses on assisting with treatment targeted at treating its cause and restoring intravascular volume. General nursing measures include ensuring safe administration of prescribed fluids and medications and documenting their administration and effects. Another important nursing role is monitoring for signs of complications and side effects of treatment and reporting these signs early in treatment.
REDISTRIBUTION OF FLUID In addition to administering fluids to restore intravascular volume, positioning the patient properly assists fluid redistribution. A modified Trendelenburg position (Fig. 15-4) is recommended in hypovolemic shock. Elevating the legs promotes the return of venous blood. Positioning the patient in a full Trendelenburg position, however, makes breathing difficult and therefore is not recommended. PHARMACOLOGIC THERAPY If fluid administration fails to reverse hypovolemic shock, then the same medications given in cardiogenic shock are used because unreversed hypovolemic shock progresses to cardiogenic shock (the vicious circle). If the underlying cause of the hypovolemia is dehydration, medications are also administered to reverse the cause of the dehydration. For example, insulin is administered if dehydration is
FIGURE 15-4
Proper positioning (modified Trendelenburg) for the patient who shows signs of shock. The lower extremities are elevated to an angle of about 20 degrees; the knees are straight, the trunk is horizontal, and the head is slightly elevated.
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ADMINISTERING BLOOD AND FLUIDS SAFELY Administering blood transfusions safely is a vital nursing role. In emergency situations, it is important to obtain blood specimens quickly to obtain a baseline complete blood count and to type and cross-match the blood in anticipation of blood transfusions. The patient who receives a transfusion of blood products must be monitored closely for adverse effects (see Chap. 33). Fluid replacement complications can occur, often when large volumes are administered rapidly. Therefore, the nurse monitors the patient closely for cardiovascular overload and pulmonary edema. The risk of these complications is increased in the elderly and in patients with pre-existing cardiac disease. Hemodynamic pressure, vital signs, arterial blood gases, hemoglobin and hematocrit levels, and fluid intake and output are among the parameters monitored. The patient’s temperature should also be monitored closely to ensure that rapid fluid resuscitation does not precipitate hypothermia. Intravenous fluids may need to be warmed during the administration of large volumes. Physical assessment focuses on observing the jugular veins for distention and monitoring jugular venous pressure. Jugular venous pressure is low in hypovolemic shock; it increases with effective treatment and is significantly increased with fluid overload and heart failure. The nurse needs to monitor cardiac and respiratory status closely and report changes in blood pressure, pulse pressure, heart rate, rhythm, and lung sounds to the physician. IMPLEMENTING OTHER MEASURES Oxygen is administered to increase the amount of oxygen carried by available hemoglobin in the blood. A patient who is confused may feel apprehensive with an oxygen mask or cannula in place, and frequent explanations about the need for the mask may reduce some of the patient’s fear and anxiety. Simultaneously, the nurse must direct efforts to the safety and comfort of the patient.
Cardiogenic Shock Cardiogenic shock occurs when the heart’s ability to contract and to pump blood is impaired and the supply of oxygen is inadequate for the heart and tissues. The causes of cardiogenic shock are known as either coronary or noncoronary. Coronary cardiogenic shock is more common than noncoronary cardiogenic shock and is seen most often in patients with myocardial infarction. Coronary cardiogenic shock occurs when a significant amount of the left ventricular myocardium has been destroyed (Price et al., 1999). Patients experiencing an anterior wall myocardial infarction are at the greatest risk for developing cardiogenic shock because of the potentially extensive damage to the left ventricle caused by occlusion of the left anterior descending coronary artery (Chart 15-4). Non-coronary causes can be related to
severe metabolic problems (severe hypoxemia, acidosis, hypoglycemia, and hypocalcemia) and tension pneumothorax.
Pathophysiology In cardiogenic shock, cardiac output, which is a function of both stroke volume and heart rate, is compromised. When stroke volume and heart rate decrease or become erratic, blood pressure drops and tissue perfusion is compromised. Along with other tissues and organs being deprived of adequate blood supply, the heart muscle itself receives inadequate blood. The result is impaired tissue perfusion. Because impaired tissue perfusion weakens the heart and impairs its ability to pump blood forward, the ventricle does not fully eject its volume of blood at systole. As a result, fluid accumulates in the lungs. This sequence of events can occur rapidly or over a period of days (Fig. 15-5).
Clinical Manifestations Patients in cardiogenic shock may experience angina pain and develop dysrhythmias and hemodynamic instability.
Medical Management The goals of medical management are to (1) limit further myocardial damage and preserve the healthy myocardium and (2) improve the cardiac function by increasing cardiac contractility, decreasing ventricular afterload, or both (Price et al., 1999). In general, these goals are achieved by increasing oxygen supply to the heart muscle while reducing oxygen demands. CORRECTION OF UNDERLYING CAUSES As with all forms of shock, the underlying cause of cardiogenic shock must be corrected. It is necessary first to treat the oxygenation needs of the heart muscle to ensure its continued ability to pump blood to other organs. In the case of coronary cardiogenic shock, the patient may require thrombolytic therapy, angioplasty, or coronary artery bypass graft surgery. In the case of noncoronary cardiogenic shock, the patient may require a cardiac valve replacement or correction of a dysrhythmia. For further explanation of these procedures, refer to Chapters 27 and 28.
Physiology/Pathophysiology
Decreased cardiac contractility
Decreased stroke volume and cardiac output
Chart 15-4
Risk Factors for Cardiogenic Shock Coronary Factors Myocardial infarction
Non-coronary Factors Cardiomyopathies Valvular damage Cardiac tamponade Dysrhythmias
Pulmonary congestion
FIGURE 15-5
Decreased systemic tissue perfusion
Decreased coronary artery perfusion
Pathophysiologic sequence of events in cardiogenic shock.
Chapter 15 INITIATION OF FIRST-LINE TREATMENT First-line treatment of cardiogenic shock involves the following actions:
• • • • • •
Supplying supplemental oxygen Controlling chest pain Providing selected fluid support Administering vasoactive medications Controlling heart rate with medication or by implementation of a transthoracic or intravenous pacemaker Implementing mechanical cardiac support (intra-aortic balloon counterpulsation therapy, ventricular assist systems, or extracorporeal cardiopulmonary bypass)
Oxygenation. In the early stages of shock, supplemental oxygen is administered by nasal cannula at a rate of 2 to 6 L/min to achieve an oxygen saturation exceeding 90%. Monitoring arterial blood gas values and pulse oximetry values helps to indicate whether the patient requires a more aggressive method of oxygen delivery. Pain Control. If the patient experiences chest pain, morphine sulfate is administered intravenously for pain relief. In addition to relieving pain, morphine dilates the blood vessels. This reduces the workload of the heart by both decreasing the cardiac filling pressure (preload) and reducing the pressure against which the heart muscle has to eject blood (afterload). Morphine also relieves the patient’s anxiety. Cardiac enzyme (CPK-MB and cTn-I) levels are measured, and serial 12-lead electrocardiograms are obtained to assess the degree of myocardial damage. Hemodynamic Monitoring. Hemodynamic monitoring is initiated to assess the patient’s response to treatment. In many institutions, this is performed in the intensive care unit, where an arterial line can be inserted. The arterial line enables accurate and continuous monitoring of blood pressure and provides a port from which to obtain frequent arterial blood samples without having to perform repeated arterial punctures. A multilumen pulmonary artery catheter is inserted to allow measurement of the pulmonary artery pressures, myocardial filling pressures, cardiac output, and pulmonary and systemic resistance. For more information, see Chapter 30. PHARMACOLOGIC THERAPY Vasoactive medication therapy consists of multiple pharmacologic strategies to restore and maintain adequate cardiac output. In coronary cardiogenic shock, the aims of vasoactive medication therapy are improved cardiac contractility, decreased preload and afterload, or stable heart rate. Because improving contractility and decreasing cardiac workload are opposing pharmacologic actions, two classifications of medications may be administered in combination: sympathomimetic agents and vasodilators. Sympathomimetic medications increase cardiac output by mimicking the action of the sympathetic nervous system through vasoconstriction, resulting in increased preload, and by increasing myocardial contractility (inotropic action) or increasing the heart rate (chronotropic action). Vasodilators are used to decrease preload and afterload, thus reducing the workload of the heart and the oxygen demand. Medications commonly combined to treat cardiogenic shock include dobutamine, dopamine, and nitroglycerin (see Table 15-1). Dobutamine. Dobutamine (Dobutrex) produces inotropic effects by stimulating myocardial beta receptors, increasing the strength
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of myocardial activity and improving cardiac output. Myocardial alpha-adrenergic receptors are also stimulated, resulting in decreased pulmonary and systemic vascular resistance (decreased afterload). Dobutamine enhances the strength of cardiac contraction, improving stroke volume ejection and overall cardiac output (Jindal et al., 2000; Price et al., 1999). Nitroglycerin. Intravenous nitroglycerin (Tridil) in low doses acts as a venous vasodilator and therefore reduces preload. At higher doses, nitroglycerin causes arterial vasodilation and therefore reduces afterload as well. These actions, in combination with medium-dose dopamine, increase cardiac output while minimizing cardiac workload. Additionally, vasodilation enhances blood flow to the myocardium, improving oxygen delivery to the weakened heart muscle (Price et al., 1999). Dopamine. Dopamine (Intropin) is a sympathomimetic agent that has varying vasoactive effects depending on the dosage. It may be used with dobutamine and nitroglycerine to improve tissue perfusion. Low-dose dopamine (0.5 to 3.0 µg/kg/min) increases renal and mesenteric blood flow, thereby preventing ischemia of these organs because shock causes blood to be shunted away from the kidneys and the mesentery. This dosage, however, does not improve cardiac output. Medium-dose dopamine (4 to 8 µg/kg/min) has sympathomimetic properties and improves contractility (inotropic action) and slightly increases the heart rate (chronotropic action). At this dosage, dopamine increases cardiac output and therefore is desirable. High-dose dopamine (8 to 10 µg/kg/min) predominantly causes vasoconstriction, which increases afterload and thus increases cardiac workload. Because this effect is undesirable in patients with cardiogenic shock, dopamine dosages must be carefully titrated. Once the patient’s blood pressure stabilizes, low-dose dopamine may be continued for its effect of promoting renal perfusion in particular. In severe metabolic acidosis, which occurs in the later stages of shock, dopamine’s effectiveness is diminished. To maximize the effectiveness of any vasoactive agent, metabolic acidosis must first be corrected. The physician may prescribe intravenous sodium bicarbonate to treat the acidosis (Jindal et al., 2000). Other Vasoactive Medications. Additional vasoactive agents that may be used in managing cardiogenic shock include norepinephrine (Levophed), epinephrine (Adrenalin), milrinone (Primacor), amrinone (Inocor), vasopressin (Pitressin), and phenylephrine (Neo-Synephrine). Each of these medications stimulates different receptors of the sympathetic nervous system. A combination of these medications may be prescribed, depending on the patient’s response to treatment. All vasoactive medications have adverse effects, making specific medications more useful than others at different stages of shock. Diuretics such as furosemide (Lasix) may be administered to reduce the workload of the heart by reducing fluid accumulation (see Table 15-1). Antiarrhythmic Medications. Antiarrhythmic medication is also part of the medication regimen in cardiogenic shock. Multiple factors, such as hypoxemia, electrolyte imbalances, and acid–base imbalances, contribute to serious cardiac dysrhythmias in all patients with shock. Additionally, as a compensatory response to decreased cardiac output and blood pressure, the heart rate increases beyond normal limits. This impedes cardiac output further by shortening diastole and thereby decreasing the time for ventricular filling. Consequently, antiarrhythmic medications are required to stabilize the heart rate. For a full discussion of cardiac
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dysrhythmias as well as commonly prescribed medications, see Chapter 27. General principles regarding the administration of vasoactive medications are discussed later in this chapter.
stances, nursing management includes working with other members of the health care team to prevent shock from progressing and to restore adequate cardiac function and tissue perfusion.
Fluid Therapy. In addition to medications, appropriate fluid is necessary in treating cardiogenic shock. Administration of fluids must be monitored closely to detect signs of fluid overload. Incremental intravenous fluid boluses are cautiously administered to determine optimal filling pressures for improving cardiac output. A fluid bolus should never be given quickly because rapid fluid administration in patients with cardiac failure may result in acute pulmonary edema.
MONITORING HEMODYNAMIC STATUS A major role of the nurse is monitoring the patient’s hemodynamic and cardiac status. Arterial lines and electrocardiographic monitoring equipment must be maintained and functioning properly. The nurse anticipates the medications, intravenous fluids, and equipment that might be used and is ready to assist in implementing these measures. Changes in hemodynamic, cardiac, and pulmonary status are documented and reported promptly. Additionally, adventitious breath sounds, changes in cardiac rhythm, and other abnormal physical assessment findings are reported immediately.
MECHANICAL ASSISTIVE DEVICES If cardiac output does not improve despite supplemental oxygen, vasoactive medications, and fluid boluses, mechanical assistive devices are used temporarily to improve the heart’s ability to pump. Intra-aortic balloon counterpulsation is one means of providing temporary circulatory assistance (see Chap. 30). A polyurethane balloon catheter is inserted percutaneously through the common femoral artery and advanced into the descending thoracic aorta. The balloon catheter is connected to a console containing a gasfilled pump. The timing of the balloon inflation is synchronized electrocardiographically with the beginning of diastole, and the balloon deflation occurs just before systole. The goals of intraaortic balloon counterpulsation include the following:
• • • • •
Increased stroke volume Improved coronary artery perfusion Decreased preload Decreased cardiac workload Decreased myocardial oxygen demand (Kumar et al., 2000)
Other means of mechanical assistance include left and right ventricular assist devices and total artificial hearts. These devices are electrical pumps or pumps driven by air. They assist or replace the ventricular pumping action of the heart. Human heart transplantation may be the only option remaining for a patient who has cardiogenic shock and who cannot be weaned from mechanical assistive devices. (Mechanical assistive devices and heart transplantation are discussed in Chap. 30.) Another short-term means of providing cardiac or pulmonary support to the patient in cardiogenic shock is through an extracorporeal device similar to the cardiopulmonary bypass (CPB) used in open-heart surgery. The CPB system requires systemic anticoagulation, arterial and venous cannulation of the femoral artery and vein, and connection to a centrifugal, oxygenated pump. The catheter tip is advanced into the right atrium. This system lowers left and right ventricular pressures, reducing the workload and oxygen needs of the heart. Complications of CPB include coagulopathies, myocardial ischemia, infection, and thromboembolism. CPB is used only in emergency situations until definitive treatment, such as heart transplantation, can be initiated.
Nursing Management PREVENTING CARDIOGENIC SHOCK In some circumstances, identifying patients at risk early and promoting adequate oxygenation of the heart muscle and decreasing cardiac workload can prevent cardiogenic shock. This can be accomplished by conserving the patient’s energy, promptly relieving angina, and administering supplemental oxygen. Often, however, cardiogenic shock cannot be prevented. In such in-
ADMINISTERING MEDICATIONS AND INTRAVENOUS FLUIDS The nurse has a critical role in safe and accurate administration of intravenous fluids and medications. Fluid overload and pulmonary edema are risks because of ineffective cardiac function and accumulation of blood and fluid in the pulmonary tissues. The nurse documents and records medications and treatments that are administered as well as the patient’s response to treatment. The nurse needs to be knowledgeable about the desired effects as well as the side effects of medications. For example, it is important to monitor the patient for decreased blood pressure after administering morphine or nitroglycerin. The patient receiving thrombolytic therapy must be monitored for bleeding. Arterial and venous puncture sites must be observed for bleeding and pressure must be applied at the sites if bleeding occurs. Neurologic assessment is essential after the administration of thrombolytic therapy to assess for the potential complication of cerebral hemorrhage associated with the therapy. Intravenous infusions must be observed closely because tissue necrosis and sloughing may occur if vasopressor medications infiltrate the tissues. Urine output, BUN, and serum creatinine levels are monitored to detect decreased renal function secondary to the effects of cardiogenic shock or its treatment. MAINTAINING INTRA-AORTIC BALLOON COUNTERPULSATION The nurse plays a critical role in caring for the patient receiving intra-aortic balloon counterpulsation (see Chap. 30). The nurse makes ongoing timing adjustments of the balloon pump to maximize its effectiveness by synchronizing it with the cardiac cycle. The patient is at great risk for circulatory compromise to the leg on the side where the catheter for the balloon has been placed; therefore, the nurse must frequently check the neurovascular status of the lower extremities. ENHANCING SAFETY AND COMFORT Throughout care, the nurse must take an active role in safeguarding the patient, enhancing comfort, and reducing anxiety. This includes administering medication to relieve chest pain, preventing infection at the multiple arterial and venous line insertion sites, protecting the skin, and monitoring respiratory function. Proper positioning of the patient promotes effective breathing without decreasing blood pressure and may also increase the patient’s comfort while reducing anxiety. Brief explanations about procedures that are being performed and the use of comforting touch often provide reassurance to the patient and family. Families are usually anxious and benefit from
Chapter 15 opportunities to see and talk to the patient. Explanations of treatments and the patient’s response to them are often comforting to family members.
Shock and Multisystem Failure
Physiology/Pathophysiology
Circulatory Shock Circulatory or distributive shock occurs when blood volume is abnormally displaced in the vasculature—for example, when blood volume pools in peripheral blood vessels. The displacement of blood volume causes a relative hypovolemia because not enough blood returns to the heart, which leads to subsequent inadequate tissue perfusion. The ability of the blood vessels to constrict helps return the blood to the heart. Thus, the vascular tone is determined both by central regulatory mechanisms, as in blood pressure regulation, and by local regulatory mechanisms, as in tissue demands for oxygen and nutrients. Therefore, circulatory shock can be caused either by a loss of sympathetic tone or by release of biochemical mediators from cells. The varied mechanisms leading to the initial vasodilation in circulatory shock further subdivide this classification of shock into three types: (1) septic shock, (2) neurogenic shock, and (3) anaphylactic shock. The different types of circulatory shock cause variations in the pathophysiologic chain of events and are explained here separately. In all types of circulatory shock, massive arterial and venous dilation allows blood to pool peripherally. Arterial dilation reduces systemic vascular resistance. Initially, cardiac output can be high in circulatory shock, both from the reduction in afterload (systemic vascular resistance) and from the heart muscle’s increased effort to maintain perfusion despite the incompetent vasculature secondary to arterial dilation. Pooling of blood in the periphery results in decreased venous return. Decreased venous return results in decreased stroke volume and decreased cardiac output. Decreased cardiac output, in turn, causes decreased blood pressure and ultimately decreased tissue perfusion. Figure 15-6 presents the pathophysiologic sequence of events in circulatory shock.
SEPTIC SHOCK Septic shock is the most common type of circulatory shock and is caused by widespread infection (Chart 15-5). Despite the increased sophistication of antibiotic therapy, the incidence of septic shock has continued to rise during the past 60 years. It is the most common cause of death in noncoronary intensive care units in the United States and the 13th leading cause of death in the U.S. population (Balk, 2000a). Elderly patients are at particular risk for sepsis because of decreased physiologic reserves and an aging immune system (Balk, 2000a; Vincent & Ferreira, 2000). Toxic shock syndrome, a specific form of septic shock, is described in Chapter 47. Nosocomial infections (infections occurring in the hospital) in critically ill patients most frequently originate in the bloodstream, lungs, and urinary tract (in decreasing order of frequency) (Richards, Edwards, Culver et al., 1999). The source of infection is an important determinant of the clinical outcome. The greatest risk of sepsis occurs in patients with bacteremia (bloodstream) and pneumonia (Simon & Trenholme, 2000). Other infections that may progress to septic shock include intra-abdominal infections, wound infections, bacteremia associated with intravascular catheters (Eggimann & Pittet, 2001), and indwelling urinary catheters. Additional risk factors that contribute to the growing incidence of septic shock are the increased awareness and identi-
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Vasodilation
Maldistribution of blood volume
Decreased venous return
Decreased stroke volume
Decreased cardiac output
Decreased tissue perfusion
FIGURE 15-6
Pathophysiologic sequence of events in circulatory shock.
fication of septic shock; the increased number of immunocompromised patients (due to malnutrition, alcoholism, malignancy, and diabetes mellitus); the increased incidence of invasive procedures and indwelling medical devices; the increased number of resistant microorganisms; and the increasingly older population (Balk, 2000a). The incidence of septic shock can be reduced by débriding wounds to remove necrotic tissue and carrying out infection control practices, including the use of meticulous aseptic technique, properly cleaning and maintaining equipment, and using thorough hand-hygiene techniques. The most common causative microorganisms of septic shock are the gram-negative bacteria; however, there is also an increased
Chart 15-5
Risk Factors for Circulatory Shock Septic Shock Immunosuppression Extremes of age (65 yr) Malnourishment Chronic illness Invasive procedures Neurogenic Shock Spinal cord injury Spinal anesthesia Depressant action of medications Glucose deficiency
Anaphylactic Shock Penicillin sensitivity Transfusion reaction Bee sting allergy Latex sensitivity
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incidence of gram-positive bacterial infections. Currently, grampositive bacteria are responsible for 50% of bacteremic events (Simon & Trenholme, 2000). Other infectious agents such as viruses and funguses also can cause septic shock. When a microorganism invades body tissues, the patient exhibits an immune response. This immune response provokes the activation of biochemical mediators associated with an inflammatory response and produces a variety of effects leading to shock. Increased capillary permeability, which leads to fluid seeping from the capillaries, and vasodilation are two such effects that interrupt the ability of the body to provide adequate perfusion, oxygen, and nutrients to the tissues and cells. Septic shock typically occurs in two phases. The first phase, referred to as the hyperdynamic, progressive phase, is characterized by a high cardiac output with systemic vasodilation. The blood pressure may remain within normal limits. The heart rate increases, progressing to tachycardia. The patient becomes hyperthermic and febrile, with warm, flushed skin and bounding pulses. The respiratory rate is elevated. Urinary output may remain at normal levels or decrease. Gastrointestinal status may be compromised as evidenced by nausea, vomiting, diarrhea, or decreased bowel sounds. The patient may exhibit subtle changes in mental status, such as confusion or agitation. The later phase, referred to as the hypodynamic, irreversible phase, is characterized by low cardiac output with vasoconstriction, reflecting the body’s effort to compensate for the hypovolemia caused by the loss of intravascular volume through the capillaries. In this phase, the blood pressure drops and the skin is cool and pale. Temperature may be normal or below normal. Heart and respiratory rates remain rapid. The patient no longer produces urine, and multiple organ dysfunction progressing to failure develops. Systemic inflammatory response syndrome (SIRS) presents clinically like sepsis. The only difference between SIRS and sepsis is that there is no identifiable source of infection. SIRS stimulates an overwhelming inflammatory immunologic and hormonal response, similar to that seen in septic patients. Despite an absence of infection, antibiotic agents may still be administered because of the possibility of unrecognized infection. Additional therapies directed to the support of the patient with SIRS are similar to those for sepsis. If the inflammatory process progresses, septic shock may develop.
Medical Management Current treatment of septic shock involves identifying and eliminating the cause of infection. Specimens of blood, sputum, urine, wound drainage, and invasive catheter tips are collected for culture using aseptic technique. Any potential routes of infection must be eliminated. Intravenous lines are removed and reinserted at other body sites. Antibiotic-coated intravenous central lines may be placed to decrease the risk of invasive line-related bacteremia in high-risk patients, such as the elderly (Eggimann & Pittet, 2001). If possible, urinary catheters are removed. Any abscesses are drained and necrotic areas débrided. Fluid replacement must be instituted to correct the hypovolemia that results from the incompetent vasculature and inflammatory response. Crystalloids, colloids, and blood products may be administered to increase the intravascular volume. PHARMACOLOGIC THERAPY If the infecting organism is unknown, broad-spectrum antibiotic agents are started until culture and sensitivity reports are received (Simon & Trenholme, 2000). A third-generation cephalosporin
plus an aminoglycoside may be prescribed initially. This combination works against most gram-negative and some gram-positive organisms. When culture and sensitivity reports are available, the antibiotic agent may be changed to one that is more specific to the infecting organism and less toxic to the patient. Research efforts show promise for improving the outcomes of septic shock. Although past treatments focused on destroying the infectious organism, emphasis is now on altering the patient’s immune response to the organism. The cell walls of gram-negative bacteria contain a lipopolysaccharide, an endotoxin released during phagocytosis (Abraham et al., 2001). Endotoxin and/or gram-positive cell wall products interact with inflammatory biochemical mediators, initiating an intense inflammatory response and systemic effects that lead to shock. Current research focuses on the development of medications that will inhibit or modulate the effects of biochemical mediators, such as endotoxin and procalcitonin (Bernard, Vincent, Laterre, et al., 2001). The focus on immunotherapy in treating septic shock is expected to shed light on how the cellular response to infection leads to shock. Recombinant human activated protein C (APC), or drotrecogin alfa (Xigris), has recently been demonstrated to reduce mortality in patients with severe sepsis (Bernard, Artigas, Dellinger et al., 2001). It has been approved by the U.S. Food and Drug Administration for treatment of adults with severe sepsis and resulting acute organ dysfunction who are at high risk of death. It acts as an antithrombotic, anti-inflammatory, and profibrinolytic agent. Its most common serious side effect is bleeding. Therefore, it is contraindicated in patients with active internal bleeding, recent hemorrhagic stroke, intracranial surgery, or head injury. NUTRITIONAL THERAPY Aggressive nutritional supplementation is critical in the management of septic shock because malnutrition further impairs the patient’s resistance to infection. Nutritional supplementation should be initiated within the first 24 hours of the onset of shock (Mizock, 2000). Enteral feedings are preferred to the parenteral route because of the increased risk of iatrogenic infection associated with intravenous catheters; however, enteral feedings may not be possible if decreased perfusion to the gastrointestinal tract reduces peristalsis and impairs absorption.
Nursing Management The nurse caring for any patient in any setting must keep in mind the risks of sepsis and the high mortality rate associated with septic shock. All invasive procedures must be carried out with aseptic technique after careful hand hygiene. Additionally, intravenous lines, arterial and venous puncture sites, surgical incisions, traumatic wounds, urinary catheters, and pressure ulcers are monitored for signs of infection in all patients. The nurse identifies patients at particular risk for sepsis and septic shock (ie, elderly and immunosuppressed patients or patients with extensive trauma or burns or diabetes), keeping in mind that these high-risk patients may not develop typical or classic signs of infection and sepsis. Confusion, for example, may be the first sign of infection and sepsis in elderly patients. When caring for the patient with septic shock, the nurse collaborates with other members of the health care team to identify the site and source of sepsis and the specific organisms involved. Appropriate specimens for culture and sensitivity are often obtained by the nurse. Elevated body temperature (hyperthermia) is common with sepsis and raises the patient’s metabolic rate and oxygen consumption. Fever is one of the body’s natural mechanisms for
Chapter 15 fighting infections. Thus, an elevated temperature may not be treated unless it reaches dangerous levels (more than 40°C [104°F]) or unless the patient is uncomfortable. Efforts may be made to reduce the temperature by administering acetaminophen or applying hypothermia blankets. During these therapies, the nurse monitors the patient closely for shivering, which increases oxygen consumption. Efforts to increase comfort are important if the patient experiences fever, chills, or shivering. The nurse administers prescribed intravenous fluids and medications, including antibiotic agents and vasoactive medications to restore vascular volume. Because of decreased perfusion to the kidneys and liver, serum concentrations of antibiotic agents that are normally cleared by these organs may increase and produce toxic effects. Therefore, the nurse monitors blood levels (antibiotic agent, BUN, creatinine, white blood count) and reports increased levels to the physician. As with other types of shock, the nurse monitors the patient’s hemodynamic status, fluid intake and output, and nutritional status. Daily weights and close monitoring of serum albumin levels help determine the patient’s protein requirements.
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knee and dorsiflexing the foot. If the patient complains of pain in the calf, the sign is positive and suggestive of deep vein thrombosis. Administering heparin or low-molecular-weight heparin (Lovenox) as prescribed, applying elastic compression stockings, or initiating pneumatic compression of the legs may prevent thrombus formation. Performing passive range of motion of the immobile extremities helps promote circulation. Patients who have experienced a spinal cord injury may not report pain caused by internal injuries. Therefore, in the immediate postinjury period, the nurse must monitor the patient closely for signs of internal bleeding that could lead to hypovolemic shock.
ANAPHYLACTIC SHOCK
In neurogenic shock, vasodilation occurs as a result of a loss of sympathetic tone. This can be caused by spinal cord injury, spinal anesthesia, or nervous system damage. It can also result from the depressant action of medications or lack of glucose (eg, insulin reaction or shock). Neurogenic shock may have a prolonged course (spinal cord injury) or a short one (syncope or fainting). It is characterized by dry, warm skin rather than the cool, moist skin seen in hypovolemic shock. Another characteristic is bradycardia, rather than the tachycardia that characterizes other forms of shock.
Anaphylactic shock is caused by a severe allergic reaction when a patient who has already produced antibodies to a foreign substance (antigen) develops a systemic antigen–antibody reaction. This process requires that the patient has previously been exposed to the substance. An antigen–antibody reaction provokes mast cells to release potent vasoactive substances, such as histamine or bradykinin, that cause widespread vasodilation and capillary permeability. Anaphylactic shock occurs rapidly and is life-threatening. Because anaphylactic shock occurs in patients already exposed to an antigen who have developed antibodies to it, it can often be prevented. Therefore, patients with known allergies need to understand the consequences of subsequent exposure to the antigen and should wear medical identification that lists their sensitivities. This could prevent inadvertent administration of a medication that would lead to anaphylactic shock. Additionally, the patient and family need instruction about emergency use of medications to treat anaphylaxis.
Medical Management
Medical Management
Treatment of neurogenic shock involves restoring sympathetic tone either through the stabilization of a spinal cord injury or, in the instance of spinal anesthesia, by positioning the patient properly. Specific treatment of neurogenic shock depends on its cause. Further discussion of managing the patient with a spinal cord injury is presented in Chapter 63. If hypoglycemia (insulin shock) is the cause, glucose is rapidly administered. Hypoglycemia and the insulin reaction are described further in Chapter 41.
Treatment of anaphylactic shock requires removing the causative antigen (eg, discontinuing an antibiotic agent), administering medications that restore vascular tone, and providing emergency support of basic life functions. Epinephrine is given for its vasoconstrictive action. Diphenhydramine (Benadryl) is administered to reverse the effects of histamine, thereby reducing capillary permeability. These medications are given intravenously. Nebulized medications, such as albuterol (Proventil), may be given to reverse histamine-induced bronchospasm. If cardiac arrest and respiratory arrest are imminent or have occurred, cardiopulmonary resuscitation is performed. Endotracheal intubation or tracheotomy may be necessary to establish an airway. Intravenous lines are inserted to provide access for administering fluids and medications. Anaphylaxis and specific chemical mediators are discussed further in Chapter 53.
NEUROGENIC SHOCK
Nursing Management It is important to elevate and maintain the head of the bed at least 30 degrees to prevent neurogenic shock when a patient is receiving spinal or epidural anesthesia. Elevation of the head of the bed helps to prevent the spread of the anesthetic agent up the spinal cord. In suspected spinal cord injury, neurogenic shock may be prevented by carefully immobilizing the patient to prevent further damage to the spinal cord. Nursing interventions are directed toward supporting cardiovascular and neurologic function until the usually transient episode of neurogenic shock resolves. Applying elastic compression stockings and elevating the foot of the bed may minimize pooling of blood in the legs. Pooled blood increases the risk for thrombus formation. Therefore, the nurse needs to check the patient daily for any redness, tenderness, warmth of the calves, and positive Homans’ sign (calf pain on dorsiflexion of the foot). To elicit Homans’ sign, the nurse lifts the patient’s leg, flexing it at the
Nursing Management The nurse has an important role in preventing anaphylactic shock: assessing all patients for allergies or previous reactions to antigens (eg, medications, blood products, foods, contrast agents, latex) and communicating the existence of these allergies or reactions to others. Additionally, the nurse assesses the patient’s understanding of previous reactions and steps taken by the patient and family to prevent further exposure to antigens. When new allergies are identified, the nurse advises the patient to wear or carry identification that names the specific allergen or antigen.
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When administering any new medication, the nurse observes the patient for an allergic reaction. This is especially important with intravenous medications. Allergy to penicillin is one of the most common causes of anaphylactic shock. Patients who have a penicillin allergy may also develop an allergy to similar medications. For example, they may react to cefazolin sodium (Ancef ) because it has a similar antimicrobial action of attaching to the penicillin-binding proteins found on the walls of infectious organisms. Previous adverse drug reactions increase the risk that an elderly patient will develop an undesirable reaction to a new medication. If the elderly patient reports an allergy to a medication, the nurse must be aware of the risks involved in the administration of similar medications. In the hospital and outpatient diagnostic testing sites, the nurse must identify patients at risk for anaphylactic reactions to contrast agents (radiopaque, dye-like substances that may contain iodine) used for diagnostic tests. These include patients with a known allergy to iodine or fish or those who have had previous allergic reactions to contrast agents. This information must be conveyed to the staff at the diagnostic testing site, including x-ray personnel. The nurse must be knowledgeable about the clinical signs of anaphylaxis, must take immediate action if signs and symptoms occur, and must be prepared to begin cardiopulmonary resuscitation if cardiorespiratory arrest occurs. In addition to monitoring the patient’s response to treatment, the nurse assists with intubation if needed, monitors the hemodynamic status, ensures intravenous access for administration of medications, administers prescribed medications and fluids, and documents treatments and their effects. Community health and home care nurses whose role includes administering medications, including antibiotic agents, in the patient’s home or other settings must be prepared to administer epinephrine subcutaneously or intramuscularly in the event of an anaphylactic reaction. After recovery from anaphylaxis, the patient and family require an explanation of the event. Further, the nurse provides instruction about avoiding future exposure to antigens and administering emergency medications to treat anaphylaxis (see Chap. 53).
Multiple Organ Dysfunction Syndrome Multiple organ dysfunction syndrome (MODS) is altered organ function in an acutely ill patient that requires medical intervention to support continued organ function. The disorder can be further categorized as primary or secondary MODS.
lular level and therefore cannot be directly observed or measured. The organ failure usually begins in the lungs and is followed by failure of the liver, gastrointestinal system, and kidneys (Balk, 2000b). Advanced age, malnutrition, and coexisting diseases appear to increase the risk of MODS in an acutely ill patient.
Clinical Manifestations The clinical course of MODS follows one of two patterns. In both patterns, there is an initial event that results in low blood pressure. The cause of the drop in blood pressure is treated, and the patient appears to respond. In the first pattern of MODS (primary MODS), which occurs most often when the initiating event is a pulmonary one such as lung injury, the patient experiences respiratory compromise that necessitates intubation. This usually occurs within 72 hours of the initiating event. Respiratory failure leads rapidly to MODS, resulting in a mortality rate of 30% to 75% (Fein & Calalag-Colucci, 2000). In secondary MODS, the pattern is more insidious. It occurs most often in the patient with septic shock and progressively unfolds over about 1 month. The patient also experiences respiratory failure and requires intubation. The patient remains hemodynamically stable for about 7 to 14 days. Despite this apparent stability, the patient exhibits a hypermetabolic state characterized by hyperglycemia (elevated blood glucose level), hyperlacticacidemia (excess of lactic acid in the blood), and polyuria (excessive urinary output). The metabolic rate is 1.5 to 2 times basal metabolic rate. Infection is usually present, and skin breakdown begins to occur. During this stage, there is a severe loss of skeletal muscle mass (autocatabolism). If the hypermetabolic phase can be reversed, patients may survive with some damage to affected organ systems (Mizock, 2000). If the hypermetabolic process cannot be halted and cells do not receive adequate oxygen and nutrients, irreversible organ failure and death occur. If the hypermetabolic phase cannot be reversed, MODS progresses and is characterized by jaundice, hyperbilirubinemia (liver failure), and oliguria progressing to anuria (renal failure), often requiring dialysis. The patient becomes less hemodynamically stable and begins to require vasoactive medications and fluid support. Because of a lack of consistent definitions to describe organ failure, the exact incidence of MODS is hard to define (Balk, 2000b; Vincent & Ferreira, 2000). However, it is reasonable to say that the onset of organ dysfunction is an ominous prognostic sign; the more organs that fail, the worse the outcome.
Medical Management Pathophysiology Primary MODS is the result of direct tissue insult, which then leads to impaired perfusion or ischemia. Secondary MODS is most often a complication of septic shock or SIRS. However, MODS may be a complication of any form of shock because of inadequate tissue perfusion. As previously described, in shock all organ systems suffer damage from a lack of adequate perfusion that can result in organ failure. A syndrome of sequential organ failure has been further observed. The exact mechanism that triggers this syndrome is unknown. Although various causes of MODS have been identified, including dead or injured tissue, infection, and perfusion deficits, it is not yet possible to predict which patients will develop MODS. This is partly because much of the organ damage occurs at the cel-
Prevention remains the top priority in managing MODS. Elderly patients are at increased risk of MODS because of the lack of physiologic reserve associated with aging and the natural degenerative process, especially immune compromise (Balk, 2000b). Early detection and documentation of initial signs of infection are essential in managing elderly patients with MODS. Subtle changes in mentation and a gradual rise in temperature are early warning signs. Other patients at risk of MODS are those with chronic illness, malnutrition, immunosuppression, and surgical or traumatic wounds. If preventive measures fail, treatment measures to reverse MODS are aimed at (1) controlling the initiating event, (2) promoting adequate organ perfusion, and (3) providing nutritional support.
Chapter 15 Nursing Management The general plan of nursing care for the patient with MODS is the same as that for the patient in septic shock. Primary nursing interventions are aimed at supporting the patient and monitoring organ perfusion until primary organ insults are halted. Providing information and support to family members is a critical role of the nurse in caring for patients with MODS. Addressing end-of-life decisions is an important role of the health care team to ensure that supportive therapies are congruent with the patient’s wishes. Gerontologic Considerations The population as a whole is aging: the most rapidly growing population group consists of people over 65 years of age. The physiologic changes associated with aging, coupled with pathologic and chronic disease states, place the older individual at increased risk of developing a state of shock and possibly MODS. Medications such as beta-blocking agents (metoprolol [Lopressor]) used to treat hypertension may mask tachycardia, a primary compensatory mechanism to increase cardiac output, during hypovolemic states. The aging immune system may not mount a truly febrile response (temperature more than 40°C), but an increasing trend in body temperature should be addressed. The heart does not function well in hypoxemic states, and the aging heart may respond to decreased myocardial oxygenation with dysrhythmias that may be misinterpreted as a normal part of the aging process. Lastly, changes in mentation may be inappropriately misinterpreted as dementia. The older individual with a sudden change in mentation should be aggressively treated for the presence of infection and organ hypoperfusion. The elderly patient can overcome shock states if signs and symptoms are treated early with aggressive and supportive therapies. Nurses play an essential role in assessing and interpreting subtle changes in the older patient’s response to illness. PROMOTING COMMUNICATION The nurse encourages frequent and open communication about treatment modalities and options to ensure that the patient’s wishes regarding medical management are met. For patients who survive MODS, communicating the goals of rehabilitation and informing the patient of progress toward those goals are essential, as the massive loss of skeletal muscle mass makes rehabilitation a long, slow process. A strong nurse–patient relationship built on effective communication will provide needed encouragement during this phase of recovery. PROMOTING HOME AND COMMUNITY-BASED CARE Teaching Patients Self-Care. The patient who experiences and survives shock may have been unable to get out of bed for an extended period of time and is likely to have a slow, prolonged recovery. The patient and family are instructed about strategies to prevent further episodes of shock by identifying the factors implicated in the initial episode. In addition, the patient and family require instruction about assessments needed to identify the complications that may occur after the patient is discharged from the hospital. Depending on the type of shock and its management, the patient or family may require instruction about treatment modalities such as emergency administration of medications, intravenous therapy, parenteral nutrition, skin care, exercise, and ambulation. The patient and family are also instructed about the need for gradual increases in ambulation and
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other activity. The need for adequate dietary intake is another crucial aspect of teaching. Continuing Care in the Home and Community. Because of the physical toll associated with recovery from shock, the patient may be cared for in an extended care facility or rehabilitation setting after hospital discharge. Alternatively, a referral may be made for home care. The home care nurse assesses the patient’s physical status and monitors recovery. The nurse also assesses the adequacy of treatments that are continued at home and the ability of the patient and family to cope with these treatments. The patient is likely to require close medical supervision until complete recovery occurs. The home care nurse reinforces the importance of continuing medical care and assists the patient and family to identify and mobilize community resources.
?
Critical Thinking Exercises
1.
A new nurse on your medical unit tells you that she believes a patient with a myocardial infarction is going into shock. She does not know if the patient is experiencing anaphylactic shock related to a medication he received or cardiogenic shock due to his cardiac disorder. How would you differentiate between anaphylactic and cardiogenic shock, and what medical treatments would you anticipate?
2.
An elderly man is admitted from a nursing home with a recent onset of confusion and combative behavior. You know that sudden changes in mental status may be an early sign of sepsis in the elderly. How would you assess this patient for the possibility of septic shock, and how would the management of the elderly patient differ from that of a younger patient?
3.
While driving through a rural area, you see a crash and stop to help. Two passengers who have been removed from the cars by passersby are seriously injured. One is bleeding profusely; the other is clutching his abdomen and chest because of severe pain. Describe the type of shock that is most likely in each of these individuals. What actions would you take at the scene to prevent shock or prevent it from progressing?
4.
A patient who has used a wheelchair for the last 10 years because of a spinal cord injury was burned when her clothing caught fire as she prepared dinner. Her burns are extensive but limited to her upper body. What types of shock are possible in this patient? What therapy directed at prevention or treatment of shock would you anticipate? Describe the rationale for the therapies that you have identified. How would this patient’s disability affect management?
REFERENCES AND SELECTED READINGS Books Baldwin, K. M., Davey, S. S., Morris, S. E., & Burger, M. (1998). Shock, multiple organ dysfunction syndrome, and burns in adults. In K. L. McCance & S. E. Huether (Eds.), Pathophysiology: The biologic basis for disease in adults and children (3d ed.). St. Louis: Mosby. Guyton, A. C., & Hall, J. E. (Eds). (2000). Textbook of medical physiology (10th ed.). Philadelphia: W. B. Saunders
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Harvey, M. A. (1998). Systemic inflammatory response syndrome and multiorgan dysfunction syndrome. In M. R. Kinney, S. B. Dunbar, J. A. Brooks-Brunn, N. Molter, & J. M. Vitello-Cicciu (Eds.), AACN’s clinical reference for critical care nursing (4th ed.). St. Louis: Mosby. McKinley, M. G. (2001). Shock. In M. L. Sole, M. L. Lamborn & J. C. Hartshorn (Eds.), Introduction to critical care nursing (3d ed.). Philadelphia: W. B. Saunders. Rauen, C. A., & Munro, N. (1998). Shock. In M. R. Kinney, S. B. Dunbar, J. A. Brooks-Brunn, N. Moleter, & J. M. Vitello-Cicciu (Eds.), AACN’s clinical reference for critical care nursing (4th ed.). St. Louis: Mosby.
Journals Abraham, E., Matthay, M. A., Dinarello, C. A., et al. (2000). Consensus conference definitions for sepsis, septic shock, acute lung injury, and acute respiratory distress syndrome: Time for a reevaluation. Critical Care Medicine, 28 (1), 232–235. Balk, R. A. (2000a). Severe sepsis and septic shock: Definitions, epidemiology, and clinical manifestations. Critical Care Clinics, 16(2), 179–192. Balk, R. A. (2000b). Pathogenesis and management of multiple organ dysfunction or failure in severe sepsis and septic shock. Critical Care Clinics, 16(2), 337–351. Bernard, G. R., Vincent, J. L., Laterre, R. F., et al. (2001). Efficacy and safety of recombinant human activated protein C for severe sepsis. New England Journal of Medicine, 344(10), 699–707. Bernard, G., Artigas, A., Dellinger, P., et al. (2001). Clinical expert roundtable discussion (session 3) at the Margaux Conference on Critical Illness: The role of activated protein C in severe sepsis. Critical Care Medicine, 29(7): Suppl 1:S75–S77. Bochud, P. Y., Glauser, M. P., & Calandra, T. (2001) International Sepsis Forum. Antibiotics in sepsis. Intensive Care Medicine, 27, Suppl 1:S33–48. Choi, P. T., Yip, G., Quinonez, L. G., & Cook, D. J. (1999). Crystalloids vs colloids in fluid resuscitation: A systematic review. Critical Care Medicine, 27(1), 200–209. Eggimann, P., & Pittet, D. (2001). Catheter-related infections in intensive care units: An overview with special emphasis on prevention. Advances in Sepsis, 1(1), 2–13. Fein, A. M., & Calalang-Colucci, M. G. (2000). Acute lung injury and acute respiratory distress syndrome in sepsis and septic shock. Critical Care Clinics, 16(2), 289–313.
International Sepsis Forum. (2001). Guidelines for the management of severe sepsis and septic shock. Intensive Care Medicine, 27, Suppl 1:S1–134. Jindal, N., Hollenberg, S. M., & Dellinger, R. P. (2000). Pharmacologic issues in the management of septic shock. Critical Care Clinics, 16(2), 233–248. Kirschenbaum, L. A., Astiz, M. E., Rackow, E. C., et al. (2000). Microvascular response in patients with cardiogenic shock. Critical Care Medicine, 28(5), 1290–1294. Kumar, A., Haery, C., & Parrillo, J. E. (2000). Myocardial dysfunction in septic shock. Critical Care Clinics, 16(2), 251–281. Manns, B. J., Lee. H., Doig, C. J., et al. (2002). An economic evaluation of activated protein C treatment for severe sepsis. New England Journal of Medicine, 347(13), 993–1000. Matthay, M. A. (2001). Severe sepsis: A new treatment with both anticoagulant and anti-inflammatory properties. New England Journal of Medicine, 344(10), 759–762. Matot, I., & Sprung, C. L. (2001). Definition of sepsis. Intensive Care Medicine, 27, Suppl 1:S3–9. Mikhail, J. (1999). Resuscitation endpoints in trauma. AACN Clinical Issues, 10(1), 10–21. Mizock, B. A. (2000). Metabolic derangements in sepsis and septic shock. Critical Care Clinics, 16(2), 319–333. Price, S., Anning, P. B., Mitchell, J. A., & Evans, T. W. (1999). Myocardial dysfunction in sepsis: Mechanisms and therapeutic implications. European Heart Journal, 20(10), 715–724. Richards, M. J., Edwards, J. R., Culver, D. H., & Gaynes, R. P. (1999). Nosocomial infections in medical intensive care units in the United States. Critical Care Medicine, 27(5), 887–892. Rivers, E., Nguyen, B., Savstad, S., et al. (2001). Early goal-directed therapy in the treatment of severe sepsis and septic shock. New England Journal of Medicine, 345(19), 1368–1377. Simon, D., & Trenholme, G. (2000). Antibiotic selection for patients with septic shock. Critical Care Clinics, 16(2), 215–229. Vincent, J. L., & Ferreira, F. L. (2000). Evaluation of organ failure: We are making progress. Intensive Care Medicine, 26(6), 1023– 1024. Vincent, J. L. (2001). International Sepsis Forum. Hemodynamic support in septic shock. Intensive Care Medicine, 27, Suppl 1:S80–92.
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Oncology: Nursing Management in Cancer Care
LEARNING OBJECTIVES
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On completion of this chapter, the learner will be able to: 1. Compare the structure and function of the normal cell and the 2. 3. 4. 5. 6. 7. 8. 9. 10. 11.
cancer cell. Differentiate between benign and malignant tumors. Identify agents and factors that have been found to be carcinogenic. Describe the significance of health education and preventive care in decreasing the incidence of cancer. Differentiate among the purposes of surgical procedures used in cancer treatment, diagnosis, prophylaxis, palliation, and reconstruction. Describe the roles of surgery, radiation therapy, chemotherapy, bone marrow transplantation, and other therapies in treating cancer. Describe the special nursing needs of patients receiving chemotherapy. Describe common nursing diagnoses and collaborative problems of patients with cancer. Use the nursing process as a framework for care of patients with cancer. Describe the concept of hospice in providing care for patients with advanced cancer. Discuss the role of the nurse in assessment and management of common oncologic emergencies.
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ancer nursing practice covers all age groups and nursing specialties and is carried out in a variety of health care settings, including the home, community, acute care institutions, and rehabilitation centers. The scope, responsibilities, and goals of cancer nursing, also called oncology nursing, are as diverse and complex as those of any nursing specialty. Because many people associate cancer with pain and death, nurses need to identify their own reactions to cancer and set realistic goals to meet the challenges inherent in caring for patients with cancer. In addition, the cancer nurse must be prepared to support the patient and family through a wide range of physical, emotional, social, cultural, and spiritual crises. Chart 16-1 identifies major areas of responsibility for nurses caring for patients with cancer.
Epidemiology Although cancer affects every age group, most cancers occur in people older than 65 years of age. Overall, the incidence of cancer is higher in men than in women and higher in industrialized sectors and nations. More than 1.2 million Americans are diagnosed each year with a cancer affecting one of various body sites (Fig. 16-1). Cancer is second only to cardiovascular disease as a leading cause of death in the United States. Each year, more than 550,000 Americans die of a malignant process. In order of frequency, the leading causes of cancer deaths in the United States are lung, prostate, and colorectal cancer in men and lung, breast, and colorectal cancer in women (Jemal, Thomas, Murray & Thun, 2002). Relative 5-year survival rates for African Americans are lower for every cancer site when compared to whites. In the United States, cancer mortality in African Americans is higher than in
any other racial group. This finding is related to the higher incidence and later stage of diagnosis among African Americans. The increased cancer morbidity and mortality for this group are largely related to economic factors, education, and barriers to health care rather than to racial characteristics (Greenlee et al., 2000).
Pathophysiology of the Malignant Process Cancer is a disease process that begins when an abnormal cell is transformed by the genetic mutation of the cellular DNA. This abnormal cell forms a clone and begins to proliferate abnormally, ignoring growth-regulating signals in the environment surrounding the cell. The cells acquire invasive characteristics, and changes occur in surrounding tissues. The cells infiltrate these tissues and gain access to lymph and blood vessels, which carry the cells to other areas of the body. This phenomenon is called metastasis (cancer spread to other parts of the body). Cancer is not a single disease with a single cause; rather, it is a group of distinct diseases with different causes, manifestations, treatments, and prognoses.
PROLIFERATIVE PATTERNS During the life span, various body tissues normally experience periods of rapid or proliferative growth that must be distinguished from malignant growth activity. Several patterns of cell growth exist: hyperplasia, metaplasia, dysplasia, anaplasia, and neoplasia (see Glossary). Cancerous cells are described as malignant neoplasms. They demonstrate uncontrolled cell growth that follows no physiologic
Glossary alopecia: hair loss anaplasia: cells that lack normal cellular characteristics and differ in shape and organization with respect to their cells of origin; usually, anaplastic cells are malignant. biologic response modifier (BRM) therapy: use of agents or treatment methods that can alter the immunologic relationship between the tumor and the host to provide a therapeutic benefit biopsy: a diagnostic procedure to remove a small sample of tissue to be examined microscopically to detect malignant cells brachytherapy: delivery of radiation therapy through internal implants cancer: a disease process whereby cells proliferate abnormally, ignoring growthregulating signals in the environment surrounding the cells carcinogenesis: process of transforming normal cells into malignant cells chemotherapy: use of drugs to kill tumor cells by interfering with cellular functions and reproduction control: containment of the growth of cancer cells cure: prolonged survival and disappearance of all evidence of disease so that the pa-
tient has the same life expectancy as anyone else in his or her age group cytokines: substances produced by cells of the immune system to enhance production and functioning of components of the immune system dysplasia: bizarre cell growth resulting in cells that differ in size, shape, or arrangement from other cells of the same type of tissue extravasation: leakage of medication from the veins into the subcutaneous tissues grading: identification of the type of tissue from which the tumor originated and the degree to which the tumor cells retain the functional and structural characteristics of the tissue of origin hyperplasia: increase in the number of cells of a tissue; most often associated with periods of rapid body growth malignant: having cells or processes that are characteristic of cancer metaplasia: conversion of one type of mature cell into another type of cell metastasis: spread of cancer cells from the primary tumor to distant sites myelosuppression: suppression of the blood cell–producing function of the bone marrow
nadir: lowest point of white blood cell depression after therapy that has toxic effects on the bone marrow neoplasia: uncontrolled cell growth that follows no physiologic demand neutropenia: abnormally low absolute neutrophil count oncology: field or study of cancer palliation: relief of symptoms associated with cancer radiation therapy: use of ionizing radiation to interrupt the growth of malignant cells stomatitis: inflammation of the oral tissues, often associated with some chemotherapeutic agents staging: process of determining the size and spread, or metastasis, of a tumor thrombocytopenia: decrease in the number of circulating platelets; associated with the potential for bleeding tumor-specific antigen (TSA): protein on the membrane of cancer cells that distinguishes the malignant cell from a benign cell of the same tissue type vesicant: substance that can cause tissue necrosis and damage, particularly when extravasated xerostomia: dry oral cavity resulting from decreased function of salivary glands
Chapter 16
Chart 16-1
Responsibilities of the Nurse in Cancer Care
• Support the idea that cancer is a chronic illness that has acute • • • • • • • • • • • • • • •
exacerbations rather than one that is synonymous with death and suffering. Assess own level of knowledge relative to the pathophysiology of the disease process. Make use of current research findings and practices in the care of the patient with cancer and his or her family. Identify patients at high risk for cancer. Participate in primary and secondary prevention efforts. Assess the nursing care needs of the patient with cancer. Assess the learning needs, desires, and capabilities of the patient with cancer. Identify nursing problems of the patient and the family. Assess the social support networks available to the patient. Plan appropriate interventions with the patient and the family. Assist the patient to identify strengths and limitations. Assist the patient to design short-term and long-term goals for care. Implement a nursing care plan that interfaces with the medical care regimen and that is consistent with the established goals. Collaborate with members of a multidisciplinary team to foster continuity of care. Evaluate the goals and resultant outcomes of care with the patient, the family, and members of the multidisciplinary team. Reassess and redesign the direction of the care as determined by the evaluation.
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demand. Benign and malignant growths are classified and named by tissue of origin, as described in Table 16-1. Benign and malignant cells differ in many cellular growth characteristics, including the method and rate of growth, ability to metastasize or spread, general effects, destruction of tissue, and ability to cause death. These differences are summarized in Table 16-2. The degree of anaplasia (lack of differentiation of cells) ultimately determines the malignant potential.
CHARACTERISTICS OF MALIGNANT CELLS Despite their individual differences, all cancer cells share some common cellular characteristics in relation to the cell membrane, special proteins, the nuclei, chromosomal abnormalities, and the rate of mitosis and growth. The cell membranes are altered in cancer cells, which affects fluid movement in and out of the cell. The cell membrane of malignant cells also contains proteins called tumor-specific antigens (for example, carcinoembryonic antigen and prostate-specific antigen), which develop as they become less differentiated (mature) over time. These proteins distinguish the malignant cell from a benign cell of the same tissue type. They may be useful in measuring the extent of disease in a person and in tracking the course of illness during treatment or relapse. Malignant cellular membranes also contain less fibronectin, a cellular cement. They are therefore less cohesive and do not adhere to adjacent cells readily.
FIGURE 16-1 Estimated leading sites of cancer incidences and deaths, 2002. Cancer Facts and Figures, 2002. American Cancer Society, Atlanta, Georgia.
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GENETICS IN NURSING PRACTICE—Concepts and Challenges in Patient Management Cancer is a genetic disease. Every phase of carcinogenesis is affected by multiple genetic mutations. Some of these mutations are inherited (present in germ-line cells), but most (90%) are somatic mutations that are acquired mutations in specific cells. EXAMPLES OF CANCERS INFLUENCED BY GENETIC FACTORS • Cowden syndrome • Familial adenomatous polyposis • Familial melanoma syndrome • Hereditary breast and ovarian cancer • Hereditary non-polyposis colon cancer • Neurofibromatosis type 1 • Retinoblastoma NURSING ASSESSMENTS FAMILY HISTORY
• Obtain information about both maternal and paternal sides • •
of family. Obtain cancer history of at least three generations. Look for clustering of cancers that occur at earlier ages, multiple primary cancers in one individual, cancer in paired organs, and two or more close relatives with the same type of cancer suggestive of hereditary cancer syndromes.
PHYSICAL ASSESSMENT
• Physical findings that may predispose the patient to cancer, • • •
such as multiple colonic polyps, suggestive of a polyposis syndrome Skin findings, such as atypical moles, that may be related to familial melanoma syndrome Multiple café au lait spots, axillary freckling, and two or more neurofibromas associated with neurofibromatosis type I Facial trichilemmomas, mucosal papillomatosis, multinodular thyroid goiter or thyroid adenomas, macrocephaly, fibrocystic breasts and other fibromas or lipomas related to Cowden syndrome
Typically, nuclei of cancer cells are large and irregularly shaped (pleomorphism). Nucleoli, structures within the nucleus that house ribonucleic acid (RNA), are larger and more numerous in malignant cells, perhaps because of increased RNA synthesis. Chromosomal abnormalities (translocations, deletions, additions) and fragility of chromosomes are commonly found when cancer cells are analyzed. Mitosis (cell division) occurs more frequently in malignant cells than in normal cells. As the cells grow and divide, more glucose and oxygen are needed. If glucose and oxygen are unavailable, malignant cells use anaerobic metabolic channels to produce energy, which makes the cells less dependent on the availability of a constant oxygen supply.
INVASION AND METASTASIS Malignant disease processes have the ability to allow the spread or transfer of cancerous cells from one organ or body part to another by invasion and metastasis. Patterns of metastasis can be partially explained by circulatory patterns and by specific affinity for certain malignant cells to bind to molecules in specific body tissue.
MANAGEMENT ISSUES SPECIFIC TO GENETICS • Assess patient’s understanding of genetic factors related to his or her cancer. • Refer for cancer risk assessment when a hereditary cancer syndrome is suspected so that patient and family can discuss inheritance, risk with other family members and availability of genetic testing. • Offer appropriate genetics information and resources. • Assess patient’s understanding of genetics information. • Provide support to patient and families with known genetic test results for hereditary cancer syndromes. • Participate in the management and coordination of riskreduction measures for those with known genetic mutations. RESOURCES AND WEBSITES American Cancer Society http://www.cancer.org—offers general information about cancer and support resources for families Gene Clinics http://www.geneclinics.org—a listing of common genetic disorders with up-to-date clinical summaries, genetic counseling, and testing information National Organization of Rare Disorders http://www.rare diseases.org—a directory of support groups and information for patients and families with rare genetic disorders National Cancer Institute http://www.cancernet.nci.nih.gov— a listing of cancers with clinical summaries and treatment reviews, information on genetic risks for cancer, listing of cancer centers providing genetic cancer risk assessment services Genetic Alliance http://www.geneticalliance.org—a directory of support groups for patients and families with genetic conditions OMIM: Online Mendelian Inheritance in Man http://www.ncbi. nlm.nih.gov/omim/stats/html—a complete listing of known inherited genetic conditions
Invasion, which refers to the growth of the primary tumor into the surrounding host tissues, occurs in several ways. Mechanical pressure exerted by rapidly proliferating neoplasms may force fingerlike projections of tumor cells into surrounding tissue and interstitial spaces. Malignant cells are less adherent and may break off from the primary tumor and invade adjacent structures. Malignant cells are thought to possess or produce specific destructive enzymes (proteinases), such as collagenases (specific to collagen), plasminogen activators (specific to plasma), and lysosomal hydrolyses. These enzymes are thought to destroy surrounding tissue, including the structural tissues of the vascular basement membrane, facilitating invasion of malignant cells. The mechanical pressure of a rapidly growing tumor may enhance this process. Metastasis is the dissemination or spread of malignant cells from the primary tumor to distant sites by direct spread of tumor cells to body cavities or through lymphatic and blood circulation. Tumors growing in or penetrating body cavities may shed cells or emboli that travel within the body cavity and seed the surfaces of other organs. This can occur in ovarian cancer when malignant cells enter the peritoneal cavity and seed the peritoneal surfaces of such abdominal organs as the liver or pancreas.
Table 16-1
• Tumors and Tissue Types
TISSUE TYPE
Epithelial Surface Glandular Connective Fibrous Adipose Cartilage Bone Blood vessels Lymph vessels Lymph tissue Muscle Smooth Striated Neural Tissue Nerve cell Glial tissue Nerve sheaths Meninges Hematologic Granulocytic Erythrocytic Plasma cells Lymphocytic Monocytic Endothelial Tissue Blood vessels Lymph vessels Endothelial lining
BENIGN TUMORS
MALIGNANT TUMORS
Papilloma Adenoma
Squamous cell carcinoma Adenocarcinoma
Fibroma Lipoma Chondroma Osteoma Hemangioma Lymphangioma
Fibrosarcoma Liposarcoma Chondrosarcoma Osteosarcoma Hemangiosarcoma Lymphangiosarcoma Lymphosarcoma
Leiomyoma Rhabdomyoma
Leiomyosarcoma Rhabdomyosarcoma
Neuroma Glioma (benign)
Neuroblastoma Glioblastoma, astrocytoma, medulloblastoma, oligodendroglioma Neurilemmal sarcoma Meningeal sarcoma
Neurilemmoma Meningioma
Myelocytic leukemia Erythrocytic leukemia Multiple myeloma Lymphocytic leukemia or lymphoma Monocytic leukemia Hemangioma Lymphangioma
Hemangiosarcoma Lymphangiosarcoma Ewing’s sarcoma
Reproduced with permission from Porth, C. M. (2002). Pathophysiology: Concepts of altered health states (6th ed.). Philadelphia: Lippincott Williams & Wilkins.
Table 16-2
• Characteristics of Benign and Malignant Neoplasms
CHARACTERISTICS
BENIGN
MALIGNANT
Cell characteristics
Well-differentiated cells that resemble normal cells of the tissue from which the tumor originated
Mode of growth Rate of growth
Tumor grows by expansion and does not infiltrate the surrounding tissues; usually encapsulated Rate of growth is usually slow
Metastasis
Does not spread by metastasis
General effects
Is usually a localized phenomenon that does not cause generalized effects unless its location interferes with vital functions Does not usually cause tissue damage unless its location interferes with blood flow
Cells are undifferentiated and often bear little resemblance to the normal cells of the tissue from which they arose Grows at the periphery and sends out processes that infiltrate and destroy the surrounding tissues Rate of growth is variable and depends on level of differentiation; the more anaplastic the tumor, the faster its growth Gains access to the blood and lymphatic channels and metastasizes to other areas of the body Often causes generalized effects, such as anemia, weakness, and weight loss
Tissue destruction
Ability to cause death
Does not usually cause death unless its location interferes with vital functions
Often causes extensive tissue damage as the tumor outgrows its blood supply or encroaches on blood flow to the area; may also produce substances that cause cell damage Usually causes death unless growth can be controlled
Reproduced with permission from Porth, C. M. (2002). Pathophysiology: Concepts of altered health states (6th ed.). Philadelphia: Lippincott Williams & Wilkins.
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Metastatic Mechanisms Lymph and blood are key mechanisms by which cancer cells spread. Angiogenesis, a mechanism by which the tumor cells are ensured a blood supply, is another important process. LYMPHATIC SPREAD The most common mechanism of metastasis is lymphatic spread, which is transport of tumor cells through the lymphatic circulation. Tumor emboli enter the lymph channels by way of the interstitial fluid that communicates with lymphatic fluid. Malignant cells also may penetrate lymphatic vessels by invasion. After entering the lymphatic circulation, malignant cells either lodge in the lymph nodes or pass between lymphatic and venous circulation. Tumors arising in areas of the body with rapid and extensive lymphatic circulation are at high risk for metastasis through lymphatic channels. Breast tumors frequently metastasize in this manner through axillary, clavicular, and thoracic lymph channels. HEMATOGENOUS SPREAD Another metastatic mechanism is hematogenous spread, by which malignant cells are disseminated through the bloodstream. Hematogenous spread is directly related to the vascularity of the tumor. Few malignant cells can survive the turbulence of arterial circulation, insufficient oxygenation, or destruction by the body’s immune system. In addition, the structure of most arteries and arterioles is far too secure to permit malignant invasion. Those malignant cells that do survive this hostile environment are able to attach to endothelium and attract fibrin, platelets, and clotting factors to seal themselves from immune system surveillance. The endothelium retracts, allowing the malignant cells to enter the basement membrane and secrete lysosomal enzymes. These enzymes then destroy surrounding body tissues and thereby allow implantation. ANGIOGENESIS Malignant cells also have the ability to induce the growth of new capillaries from the host tissue to meet their needs for nutrients and oxygen. This process is referred to as angiogenesis. It is through this vascular network that tumor emboli can enter the systemic circulation and travel to distant sites. Large tumor emboli that become trapped in the microcirculation of distant sites may further metastasize to other sites. Research into ways to prevent angiogenesis is ongoing.
Carcinogenesis Malignant transformation, or carcinogenesis, is thought to be at least a three-step cellular process: initiation, promotion, and progression. In initiation, the first step, initiators (carcinogens), such as chemicals, physical factors, and biologic agents, escape normal enzymatic mechanisms and alter the genetic structure of the cellular DNA. Normally, these alterations are reversed by DNA repair mechanisms, or the changes initiate programmed cellular suicide (apoptosis). Occasionally, cells escape these protective mechanisms, and permanent cellular mutations occur. These mutations usually are not significant to cells until the second step of carcinogenesis. During promotion, repeated exposure to promoting agents (co-carcinogens) causes the expression of abnormal or mutant ge-
netic information even after long latency periods. Latency periods for the promotion of cellular mutations vary with the type of agent and the dosage of the promoter as well as the innate characteristics of the target cell. Cellular oncogenes, present in all mammalian systems, are responsible for the vital cellular functions of growth and differentiation. Cellular proto-oncogenes are present in cells and act as an “on switch” for cellular growth. Similarly, cancer suppressor genes “turn off” or regulate unneeded cellular proliferation. When the suppressor genes become mutated, rearranged, or amplified or lose their regulatory capabilities, malignant cells are allowed to reproduce. The p53 gene is a tumor suppressor gene that is frequently mutated in many human cancers. This gene regulates whether cells will repair or die after DNA damage. Mutant p53 gene is associated with a poor prognosis and may be associated with determining response to treatment. Once this genetic expression occurs in cells, the cells begin to produce mutant cell populations that are different from their original cellular ancestors. Progression is the third step of cellular carcinogenesis. The cellular changes formed during initiation and promotion now exhibit increased malignant behavior. These cells now show a propensity to invade adjacent tissues and to metastasize. Agents that initiate or promote cellular transformation are referred to as carcinogens.
ETIOLOGY Certain categories of agents or factors implicated in carcinogenesis include viruses and bacteria, physical agents, chemical agents, genetic or familial factors, dietary factors, and hormonal agents.
Viruses and Bacteria Viruses as a cause of human cancers are hard to determine because viruses are difficult to isolate. Infectious causes are considered or suspected, however, when specific cancers appear in clusters. Viruses are thought to incorporate themselves in the genetic structure of cells, thus altering future generations of that cell population— perhaps leading to a cancer. For example, the Epstein-Barr virus is highly suspect as a cause in Burkitt’s lymphoma, nasopharyngeal cancers, and some types of non-Hodgkin’s lymphoma and Hodgkin’s disease. Herpes simplex virus type II, cytomegalovirus, and human papillomavirus types 16, 18, 31, and 33 are associated with dysplasia and cancer of the cervix. The hepatitis B virus is implicated in cancer of the liver; the human T-cell lymphotropic virus may be a cause of some lymphocytic leukemias and lymphomas; and the human immunodeficiency virus (HIV ) is associated with Kaposi’s sarcoma. The bacterium Helicobacter pylori has been associated with an increased incidence of gastric malignancy, perhaps secondary to inflammation and injury of gastric cells.
Physical Agents Physical factors associated with carcinogenesis include exposure to sunlight or radiation, chronic irritation or inflammation, and tobacco use. Excessive exposure to the ultraviolet rays of the sun, especially in fair-skinned, blue- or green-eyed people, increases the
Chapter 16 risk for skin cancers. Factors such as clothing styles (sleeveless shirts or shorts), use of sunscreens, occupation, recreational habits, and environmental variables, including humidity, altitude, and latitude, all play a role in the amount of exposure to ultraviolet light. Exposure to ionizing radiation can occur with repeated diagnostic x-ray procedures or with radiation therapy used to treat disease. Fortunately, improved x-ray equipment appropriately minimizes the risk for extensive radiation exposure. Radiation therapy used in disease treatment or exposure to radioactive materials at nuclear weapon manufacturing sites or nuclear power plants is associated with a higher incidence of leukemias, multiple myeloma, and cancers of the lung, bone, breast, thyroid, and other tissues. Background radiation from the natural decay processes that produce radon has also been associated with lung cancer. Homes with high levels of trapped radon should be ventilated to allow the gas to disperse into the atmosphere.
Chemical Agents About 75% of all cancers are thought to be related to the environment. Tobacco smoke, thought to be the single most lethal chemical carcinogen, accounts for at least 30% of cancer deaths (Heath & Fontham, 2001). Smoking is strongly associated with cancers of the lung, head and neck, esophagus, pancreas, cervix, and bladder. Tobacco may also act synergistically with other substances, such as alcohol, asbestos, uranium, and viruses, to promote cancer development. Chewing tobacco is associated with cancers of the oral cavity and primarily occurs in men younger than 40 years of age. Many chemical substances found in the workplace have proved to be carcinogens or co-carcinogens. The extensive list of suspected chemical substances continues to grow and includes aromatic amines and aniline dyes; pesticides and formaldehydes; arsenic, soot, and tars; asbestos; benzene; betel nut and lime; cadmium; chromium compounds; nickel and zinc ores; wood dust; beryllium compounds; and polyvinyl chloride. Most hazardous chemicals produce their toxic effects by altering DNA structure in body sites distant from chemical exposure. The liver, lungs, and kidneys are the organ systems most often affected, presumably because of their roles in detoxifying chemicals.
Genetic and Familial Factors Almost every cancer type has been shown to run in families. This may be due to genetics, shared environments, cultural or lifestyle factors, or chance alone. Genetic factors play a role in cancer cell development. Abnormal chromosomal patterns and cancer have been associated with extra chromosomes, too few chromosomes, or translocated chromosomes. Specific cancers with underlying genetic abnormalities include Burkitt’s lymphoma, chronic myelogenous leukemia, meningiomas, acute leukemias, retinoblastomas, Wilms’ tumor, and skin cancers, including malignant melanoma. Approximately 5% to 10% of cancers of adulthood and childhood display a familial predisposition. Inherited cancer syndromes, such as premenopausal breast cancer, tend to occur at an early age and at multiple sites in one organ or pair of organs. In cancers with a familial predisposition, individuals may develop multiple cancers; commonly, two or more first-degree relatives
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share the same cancer type. Cancers associated with familial inheritance include retinoblastomas, nephroblastomas, pheochromocytomas, malignant neurofibromatosis, and breast, ovarian, endometrial, colorectal, stomach, prostate, and lung cancers. In 1994, the BRCA-1 gene was identified; it is linked to breast and ovarian cancer syndrome. The BRCA-2 gene, which has also been identified, is associated with early-onset breast cancer (Nogueira & Appling, 2000). Work continues to identify other specific genes related to cancer incidence (Greco, 2000).
Dietary Factors Dietary factors are thought to be related to 35% of all environmental cancers (Heath & Fontham, 2001). Dietary substances can be proactive (protective), carcinogenic, or co-carcinogenic. The risk for cancer increases with long-term ingestion of carcinogens or co-carcinogens or chronic absence of proactive substances in the diet. Dietary substances associated with an increased cancer risk include fats, alcohol, salt-cured or smoked meats, foods containing nitrates and nitrites, and a high caloric dietary intake. Food substances that appear to reduce cancer risk include high-fiber foods, cruciferous vegetables (cabbage, broccoli, cauliflower, Brussels sprouts, kohlrabi), carotenoids (carrots, tomatoes, spinach, apricots, peaches, dark-green and deep-yellow vegetables), and possibly vitamins E and C, zinc, and selenium. Obesity is associated with endometrial cancer and possibly postmenopausal breast cancers. Obesity may also increase the risk for cancers of the colon, kidney, and gallbladder.
Hormonal Agents Tumor growth may be promoted by disturbances in hormonal balance either by the body’s own (endogenous) hormone production or by administration of exogenous hormones. Cancers of the breast, prostate, and uterus are thought to depend on endogenous hormonal levels for growth. Diethylstilbestrol (DES) has long been recognized as a cause of vaginal carcinomas. Oral contraceptives and prolonged estrogen replacement therapy are associated with increased incidence of hepatocellular, endometrial, and breast cancers, whereas they appear to decrease the risk for ovarian and endometrial cancers. The combination of estrogen and progesterone appears safest in decreasing the risk for endometrial cancers. Hormonal changes with reproduction are also associated with cancer incidence. Increased numbers of pregnancies are associated with a decreased incidence of breast, endometrial, and ovarian cancers.
ROLE OF THE IMMUNE SYSTEM In humans, malignant cells are capable of developing on a regular basis. Some evidence indicates, however, that the immune system can detect the development of malignant cells and destroy them before cell growth becomes uncontrolled. When the immune system fails to identify and stop the growth of malignant cells, clinical cancer develops. Patients who for various reasons are immunoincompetent have been shown to have an increased incidence of cancer. Organ transplant recipients who receive immunosuppressive therapy to prevent rejection of the transplanted organ have an increased
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incidence of lymphoma, Kaposi’s sarcoma, squamous cell cancer of the skin, and cervical and anogenital cancers. Patients with immunodeficiency diseases, such as AIDS, have an increased incidence of Kaposi’s sarcoma, lymphoma, and rectal and head and neck cancers. Some patients who have received alkylating chemotherapeutic agents to treat Hodgkin’s disease have an increased incidence of secondary malignancies. Autoimmune diseases, such as rheumatoid arthritis and Sjögren’s syndrome, are associated with increased cancer development. Finally, age-related changes, such as declining organ function, increased incidence of chronic diseases, and diminished immunocompetence, may contribute to an increased incidence of cancer in older people.
Normal Immune Responses Normally, an intact immune system has the ability to combat cancer cells in several ways. Usually, the immune system recognizes as foreign certain antigens on the cell membranes of many cancer cells. These antigens are known as tumor-associated antigens (also called tumor cell antigens) and are capable of stimulating both cellular and humoral immune responses. Along with the macrophages, T lymphocytes, the soldiers of the cellular immune response, are responsible for recognizing tumor-associated antigens. When T lymphocytes recognize tumor antigens, other T lymphocytes that are toxic to the tumor cells are stimulated. These lymphocytes proliferate and are released into the circulation. In addition to possessing cytotoxic (cell-killing) properties, T lymphocytes can stimulate other components of the immune system to rid the body of malignant cells. Certain lymphokines, which are substances produced by lymphocytes, are capable of killing or damaging various types of malignant cells. Other lymphokines can mobilize other cells, such as macrophages, that disrupt cancer cells. Interferon (IFN), a substance produced by the body in response to viral infection, also possesses some antitumor properties. Antibodies produced by B lymphocytes, associated with the humoral immune response, also defend the body against malignant cells. These antibodies act either alone or in combination with the complement system or the cellular immune system. Natural killer (NK) cells are a major component of the body’s defense against cancer. NK cells are a subpopulation of lymphocytes that act by directly destroying cancer cells or by producing lymphokines and enzymes that assist in cell destruction.
Immune System Failure How is it, then, that malignant cells can survive and proliferate despite the elaborate immune system defense mechanisms? Several theories suggest how tumor cells can evade an apparently intact immune system. If the body fails to recognize the malignant cell as different from “self” (non-self or foreign), the immune response may not be stimulated. When tumors do not possess tumor-associated antigens that label them as foreign, the immune response is not alerted. The failure of the immune system to respond promptly to the malignant cells allows the tumor to grow too large to be managed by normal immune mechanisms. Tumor antigens may combine with the antibodies produced by the immune system and hide or disguise themselves from normal immune defense mechanisms. These tumor antigen–antibody complexes can suppress further production of antibodies. Tumors are also capable of changing their appearance or producing substances that impair usual immune responses. These substances not only promote tumor growth but also increase the patient’s
susceptibility to infection by various pathogenic organisms. As a result of prolonged contact with a tumor antigen, the patient’s body may be depleted of the specific lymphocytes and no longer able to mount an appropriate immune response. Abnormal concentrations of host suppressor T lymphocytes may play a role in developing cancers. Suppressor T lymphocytes normally assist in regulating antibody production and diminishing immune responses when they are no longer required. Low levels of serum antibodies and high levels of suppressor cells have been found in patients with multiple myeloma, a cancer associated with hypogammaglobulinemia (low amounts of serum antibodies). Carcinogens, such as viruses and certain chemicals, including chemotherapeutic agents, may weaken the immune system and ultimately enhance tumor growth.
Detection and Prevention of Cancer Nurses and physicians have traditionally been involved with tertiary prevention, the care and rehabilitation of the patient after cancer diagnosis and treatment. In recent years, however, the American Cancer Society, the National Cancer Institute, clinicians, and researchers have placed greater emphasis on primary and secondary prevention of cancer. Primary prevention is concerned with reducing the risks of cancer in healthy people. Secondary prevention involves detection and screening to achieve early diagnosis and prompt intervention to halt the cancer process.
PRIMARY PREVENTION By acquiring the knowledge and skills necessary to educate the community about cancer risk, nurses in all settings play a key role in cancer prevention. Assisting patients to avoid known carcinogens is one way to reduce the risk for cancer. Another way involves adopting dietary and various lifestyle changes that epidemiologic and laboratory studies show influence the risk for cancer. Several clinical trials have been undertaken to identify medications that may help to reduce the incidence of certain types of cancer. Recently, a breast cancer prevention study supported by the National Cancer Institute was conducted at multiple medical centers throughout the country. The results of this study indicated that the medication tamoxifen can reduce the incidence of breast cancer by 49% in postmenopausal women identified as at high risk for breast cancer (Fisher et al., 1998). Nurses can use their teaching and counseling skills to encourage patients to participate in cancer prevention programs and to promote healthful lifestyles.
SECONDARY PREVENTION The evolving understanding of the role of genetics in cancer cell development has contributed to prevention and screening efforts. Individuals who have inherited specific genetic mutations have an increased susceptibility to cancer. For example, individuals who have familial adenomatosis polyposis have an increased risk for colon cancer. Women in whom the BRCA-1 and BRCA-2 genes have been identified have an increased risk for breast and ovarian cancer. To provide individualized education and recommendations for continued surveillance and care in high-risk populations, nurses need to be familiar with ongoing developments in the field of genetics and cancer (Greco, 2000). Many centers across the country are offering innovative cancer risk evaluation programs that provide in-depth screening and follow-up for individuals who are found to be at high risk for cancer.
Chapter 16 Numerous factors, such as race, cultural influences, access to care, physician–patient relationship, level of education, income, and age, influence the knowledge, attitudes, and beliefs people have about cancer. These factors also influence the type of healthpromoting behaviors they practice. For example, Phillips, Cohen, and Moses (1999) examined beliefs, attitudes, and practices related to breast cancer and breast cancer screening in African American women (Nursing Research Profile 16-1). They found that cultural, spiritual, and socioeconomic factors seen in the women studied could be identified as barriers to breast health screening behaviors. Nurses can use this type of information in planning education, prevention, and screening programs. Public awareness about health-promoting behaviors can be increased in a variety of ways. Health education and health maintenance programs are sponsored by community organizations such as churches, senior citizen groups, and parent–teacher associations. Although primary prevention programs may focus on the hazards of tobacco use or the importance of nutrition, secondary prevention programs may promote breast and testicular self-examination and Papanicolaou (Pap) tests. Many organizations conduct cancer screening events that focus on cancers with the highest incidence rates or those that have improved survival rates if diagnosed early, such as breast or prostate cancers. These events offer education and examinations such as mammograms, digital rectal examinations, and prostate-specific antigen blood tests for minimal or no cost. Programs of this nature are often targeted to individuals who lack access to health care or cannot afford to participate on their own. Similarly, nurses in all settings can develop programs that identify risks for patients and families and that incorporate teaching and counseling into all educational efforts, particularly for patients and families with a high incidence of cancer. The American Cancer Society has developed a public education program, “Taking Control,” that integrates diet, exercise, and general health habit tips that people can follow to reduce their risk for cancer (Chart 16-2). Nurses and physicians can encourage individuals to comply with detection efforts as suggested by the American Cancer Society (Table 16-3).
Diagnosis of Cancer and Related Nursing Considerations A cancer diagnosis is based on assessment for physiologic and functional changes and results of the diagnostic evaluation. Patients with suspected cancer undergo extensive testing to (1) determine the presence of tumor and its extent, (2) identify possible spread (metastasis) of disease or invasion of other body tissues, (3) evaluate the function of involved and uninvolved body systems and organs, and (4) obtain tissue and cells for analysis, including evaluation of tumor stage and grade. The diagnostic evaluation is guided by information obtained through a complete history and physical examination. Knowledge of suspicious symptoms and of the behavior of particular types of cancer assists in determining which diagnostic tests are most appropriate (Table 16-4). A patient undergoing extensive testing is usually fearful of the procedures and anxious about the possible test results. The nurse can help relieve fear and anxiety by explaining the tests to be performed, the sensations likely to be experienced, and the patient’s role in the test procedures. The nurse encourages the patient and family to voice their fears about the test results, supports the patient and family throughout the test period, and reinforces and clarifies information conveyed by the physician. The nurse also
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Chart 16-2
Risk Factors: Taking Steps to Reduce Cancer Risk When teaching individual patients or groups, nurses can recommend the following cancer prevention strategies: 1. Increase consumption of fresh vegetables (especially those of the cabbage family) because studies indicate that roughage and vitamin-rich foods help to prevent certain kinds of cancer. 2. Increase fiber intake because high-fiber diets may reduce the risk for certain cancers (eg, breast, prostate, and colon). 3. Increase intake of vitamin A, which reduces the risk for esophageal, laryngeal, and lung cancers. 4. Increase intake of foods rich in vitamin C, such as citrus fruits and broccoli, which are thought to protect against stomach and esophageal cancers. 5. Practice weight control because obesity is linked to cancers of the uterus, gallbladder, breast, and colon. 6. Reduce intake of dietary fat because a high-fat diet increases the risk for breast, colon, and prostate cancers. 7. Practice moderation in consumption of salt-cured, smoked, and nitrate-cured foods; these have been linked to esophageal and gastric cancers. 8. Stop smoking cigarettes and cigars, which are carcinogens. 9. Reduce alcohol intake because drinking large amounts of alcohol increases the risk of liver cancer. (Note: People who drink heavily and smoke are at greater risk for cancers of the mouth, throat, larynx, and esophagus.) 10. Avoid overexposure to the sun, wear protective clothing, and use a sunscreen to prevent skin damage from ultraviolet rays that increase the risk of skin cancer. Adapted from the “Taking Control” program of the American Cancer Society.
encourages the patient and family members to communicate and share their concerns and to discuss their questions and concerns with each other.
TUMOR STAGING AND GRADING A complete diagnostic evaluation includes identifying the stage and grade of the tumor. This is accomplished before treatment begins to provide baseline data for evaluating outcomes of therapy and to maintain a systematic and consistent approach to ongoing diagnosis and treatment. Treatment options and prognosis are determined on the basis of staging and grading. Staging determines the size of the tumor and the existence of metastasis. Several systems exist for classifying the anatomic extent of disease. The TNM system is frequently used. In this system, T refers to the extent of the primary tumor, N refers to lymph node involvement, and M refers to the extent of metastasis (Chart 16-3). A variety of other staging systems are used to describe the extent of cancers, such as central nervous system cancers, hematologic cancers, and malignant melanoma, that the TNM system does not describe appropriately. Staging systems also provide a convenient shorthand notation that condenses lengthy descriptions into manageable terms for comparisons of treatments and prognoses. Grading refers to the classification of the tumor cells. Grading systems seek to define the type of tissue from which the tumor originated and the degree to which the tumor cells retain the
Table 16-3
• American Cancer Society Recommendations for Early Detection of Cancer in Asymptomatic, Average-Risk People
SITE
GENDER
AGE
EVALUATION
FREQUENCY
Breast
F
20–39
Clinical breast examination (CBE) Breast self-examination (BSE) Clinical breast examination (CBE) Breast self-examination (BSE) Mammogram Fecal occult blood test and Flexible sigmoidoscopy or Colonoscopy or Double-contrast barium enema Prostate-specific antigen and digital rectal examination (DRE) Papanicolaou (Pap) test* Pelvic examination
Every 3 years Every month Every year Every month Every year Every year
Checkup that includes examination for cancers of the thyroid, testicles, ovaries, lymph nodes, oral cavity, and skin as well as counseling about health practices and risk factors
Every 3 years
≥ 40
Colon/rectum
M/F
Prostate
M
Cervix
F
Cancer-related checkups
M/F
≥ 50
≥ 50 (or 90%
1
• O2 sat 24 breaths/minute
Hypoventilation
Shallow, irregular breathing
Hyperventilation
Increased rate and depth of breathing (called Kussmaul's respiration if caused by diabetic ketoacidosis)
Apnea
Period of cessation of breathing. Time duration varies; apnea may occur briefly during other breathing disorders, such as with sleep apnea. Life threatening if sustained.
Cheyne-Stokes
Regular cycle where the rate and depth of breathing increase, then decrease until apnea (usually about 20 seconds) occurs.
Biot's respiration
Periods of normal breathing (3-4 breaths) followed by a varying period of apnea (usually 10 seconds to 1 minute).
FIGURE 21-10
Graphic representation of different rates and depths of respiration.
Graphic Representation
Chapter 21
FIGURE 21-11
Method for assessing posterior respiratory excursion. Place both hands posteriorly at the level of T9 or T10. Slide hands medially to pinch a small amount of skin between your thumbs. Observe for symmetry.
Decreased chest excursion may be due to chronic fibrotic disease. Asymmetric excursion may be due to splinting secondary to pleurisy, fractured ribs, trauma, or unilateral bronchial obstruction. TACTILE FREMITUS Sound generated by the larynx travels distally along the bronchial tree to set the chest wall in resonant motion. This is especially
FIGURE 21-12
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true of consonant sounds. The detection of the resulting vibration on the chest wall by touch is called tactile fremitus. Normal fremitus is widely varied. It is influenced by the thickness of the chest wall, especially if that thickness is muscular. However, the increase in subcutaneous tissue associated with obesity may also affect fremitus. Lower-pitched sounds travel better through the normal lung and produce greater vibration of the chest wall. Thus, fremitus is more pronounced in men than in women because of the deeper male voice. Normally, fremitus is most pronounced where the large bronchi are closest to the chest wall and least palpable over the distant lung fields. Therefore, it is most palpable in the upper thorax, anteriorly and posteriorly. The patient is asked to repeat “ninety-nine” or “one, two, three,” or “eee, eee, eee” as the nurse’s hands move down the patient’s thorax. The vibrations are detected with the palmar surfaces of the fingers and hands, or the ulnar aspect of the extended hands, on the thorax. The hand or hands are moved in sequence down the thorax. Corresponding areas of the thorax are compared (Fig. 21-12). Bony areas are not tested. Air does not conduct sound well but a solid substance such as tissue does, provided that it has elasticity and is not compressed. Thus, an increase in solid tissue per unit volume of lung will enhance fremitus; an increase in air per unit volume of lung will impede sound. Patients with emphysema, which results in the rupture of alveoli and trapping of air, exhibit almost no tactile fremitus. A patient with consolidation of a lobe of the lung from pneumonia will have increased tactile fremitus over that lobe. Air in the pleural space will not conduct sound.
Thoracic Percussion Percussion sets the chest wall and underlying structures in motion, producing audible and tactile vibrations. The nurse uses percussion to determine whether underlying tissues are filled with air, fluid, or solid material. Percussion also is used to estimate the size and location of certain structures within the thorax (eg, diaphragm, heart, liver).
When palpating for tactile fremitus (left), the nurse places the ball or ulnar surface of the hands on the chest area being assessed. The palpation sequence is at right. From Bickley L. S. (2003). Bates’ guide to physical examination and history taking (8th ed.). Philadelphia: Lippincott Williams & Wilkins.
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Percussion usually begins with the posterior thorax. Ideally, the patient is in a sitting position with the head flexed forward and the arms crossed on the lap. This position separates the scapulae widely and exposes more lung area for assessment. The nurse percusses across each shoulder top, locating the 5-cm width of resonance overlying the lung apices (Fig. 21-13). Then the nurse proceeds down the posterior thorax, percussing symmetric areas at 5- to 6-cm (2- to 2.5-inch) intervals. The middle finger is positioned parallel to the ribs in the intercostal space; the finger is placed firmly against the chest wall before striking it with the middle finger of the opposite hand. Bony structures (scapulae or ribs) are not percussed. Percussion over the anterior chest is performed with the patient in an upright position with shoulders arched backward and arms at the side. The nurse begins in the supraclavicular area and proceeds downward, from one intercostal space to the next. In the female patient, it may be necessary to displace the breasts for an adequate examination. Dullness noted to the left of the sternum between the third and fifth intercostal spaces is a normal finding because it is the location of the heart. Similarly, there is a normal span of liver dullness in the right thorax from the fifth intercostal space to the right costal margin at the midclavicular line. The anterior and lateral thorax is examined with the patient in a supine position. If the patient cannot sit up, percussion of the posterior thorax is performed with the patient positioned on the side. Dullness over the lung occurs when air-filled lung tissue is replaced by fluid or solid tissue. Table 21-3 reviews percussion sounds and their characteristics. DIAPHRAGMATIC EXCURSION The normal resonance of the lung stops at the diaphragm. The position of the diaphragm is different during inspiration than during expiration.
To assess the position and motion of the diaphragm, the nurse instructs the patient to take a deep breath and hold it while the maximal descent of the diaphragm is percussed. The point at which the percussion note at the midscapular line changes from resonance to dullness is marked with a pen. The patient is then instructed to exhale fully and hold it while the nurse again percusses downward to the dullness of the diaphragm. This point is also marked. The distance between the two markings indicates the range of motion of the diaphragm. Maximal excursion of the diaphragm may be as much as 8 to 10 cm (3 to 4 inches) in healthy, tall young men, but for most people it is usually 5 to 7 cm (2 to 2.75 inches). Normally, the diaphragm is about 2 cm (0.75 inches) higher on the right because of the position of the heart and the liver above and below the left and right segments of the diaphragm, respectively. Decreased diaphragmatic excursion may occur with pleural effusion and emphysema. An increase in intra-abdominal pressure, as in pregnancy or ascites, may account for a diaphragm that is positioned high in the thorax.
Thoracic Auscultation Auscultation is useful in assessing the flow of air through the bronchial tree and in evaluating the presence of fluid or solid obstruction in the lung structures. The nurse auscultates for normal breath sounds, adventitious sounds, and voice sounds. Examination includes auscultation of the anterior, posterior, and lateral thorax and is performed as follows. The nurse places the diaphragm of the stethoscope firmly against the chest wall as the patient breathes slowly and deeply through the mouth. Corresponding areas of the chest are auscultated in a systematic fashion from the apices to the bases and along midaxillary lines. The sequence of auscultation and the positioning of the patient are similar to those used for percussion. It often is necessary to listen to two full inspirations and expirations at each anatomic location for valid interpretation of the sound heard. Repeated deep breaths may result in symptoms of hyperventilation (eg, light-headedness); this is avoided by having the patient rest and breathe normally periodically during the examination. BREATH SOUNDS Normal breath sounds are distinguished by their location over a specific area of the lung and are identified as vesicular, bronchovesicular, and bronchial (tubular) breath sounds (Table 21-4). The location, quality, and intensity of breath sounds are determined during auscultation. When airflow is decreased by bronchial obstruction (atelectasis) or when fluid (pleural effusion) or tissue (obesity) separates the air passages from the stethoscope, breath sounds are diminished or absent. For example, the breath sounds of the patient with emphysema are faint or often completely inaudible. When heard, the expiratory phase is prolonged. Bronchial and bronchovesicular sounds that are audible anywhere except over the main bronchus in the lungs signify pathology, usually indicating consolidation in the lung (eg, pneumonia, heart failure). This finding requires further evaluation.
FIGURE 21-13
Percussion of the posterior thorax. With the patient in a sitting position, symmetric areas of the lungs are percussed at 5-cm intervals. This progression starts at the apex of each lung and concludes with percussion of each lateral chest wall.
ADVENTITIOUS SOUNDS An abnormal condition that affects the bronchial tree and alveoli may produce adventitious (additional) sounds. Adventitious sounds are divided into two categories: discrete, noncontinuous sounds (crackles) and continuous musical sounds (wheezes). The duration of the sound is the important distinction to make in identifying the sound as noncontinuous or continuous. Pleural friction rubs are specific examples of crackles (Table 21-5).
Chapter 21
Table 21-3
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• Characteristics of Percussion Sounds
SOUND
RELATIVE INTENSITY
RELATIVE PITCH
RELATIVE DURATION
LOCATION EXAMPLE
Flatness Dullness Resonance
Soft Medium Loud
High Medium Low
Short Medium Long
Thigh Liver Normal lung
Hyperresonance
Very loud
Lower
Longer
None normally
Tympany
Loud
High*
*
Gastric air bubble or puffed-out cheek
EXAMPLES
Large pleural effusion Lobar pneumonia Simple chronic bronchitis Emphysema, pneumothorax Large pneumothorax
*Distinguished mainly by its musical timbre
Crackles (formerly referred to as rales) are discrete, noncontinuous sounds that result from delayed reopening of deflated airways. Crackles may or may not be cleared by coughing. Crackles reflect underlying inflammation or congestion and are often present in such conditions as pneumonia, bronchitis, heart failure, bronchiectasis, and pulmonary fibrosis. Friction rubs result from inflammation of the pleural surfaces that induces a crackling, grating sound usually heard in inspiration and expiration. The sound can be enhanced by applying pressure to the chest wall with the diaphragm of the stethoscope. The sound is imitated by rubbing the thumb and index finger together near the ear. A friction rub is best heard over the lower lateral anterior surface of the thorax. Wheezes are associated with bronchial wall oscillation and changes in airway diameter. Wheezes are commonly heard in patients with asthma, chronic bronchitis, and bronchiectasis. VOICE SOUNDS The sound heard through the stethoscope as the patient speaks is known as vocal resonance. The vibrations produced in the larynx are transmitted to the chest wall as they pass through the bronchi and alveolar tissue. During the process, the sounds are dimin-
Table 21-4
ished in intensity and altered so that syllables are not distinguishable. Voice sounds are usually assessed by having the patient repeat “ninety-nine” or “eee” while the nurse listens with the stethoscope in corresponding areas of the chest from the apices to the bases. Bronchophony describes vocal resonance that is more intense and clearer than normal. Egophony describes voice sounds that are distorted. It is best appreciated by having the patient repeat the letter E. The distortion produced by consolidation transforms the sound into a clearly heard A rather than E. Bronchophony and egophony have precisely the same significance as bronchial breathing with an increase in tactile fremitus. When an abnormality is detected, it should be evident using more than one assessment method. A change in tactile fremitus is more subtle and can be missed, but bronchial breathing and bronchophony can be noted loudly and clearly. Whispered pectoriloquy is a very subtle finding, heard only in the presence of rather dense consolidation of the lungs. Transmission of high-frequency components of sound is so enhanced by the consolidated tissue that even whispered words are heard, a circumstance not noted in normal physiology. The significance is the same as that of bronchophony.
• Breath Sounds DURATION OF SOUNDS
INTENSITY OF EXPIRATORY SOUND
PITCH OF EXPIRATORY SOUND
LOCATIONS WHERE HEARD NORMALLY
Vesicular*
Inspiratory sounds last longer than expiratory ones.
Soft
Relatively low
Entire lung field except over the upper sternum and between the scapulae
Bronchovesicular
Inspiratory and expiratory sounds are about equal.
Intermediate
Intermediate
Often in the 1st and 2nd interspaces anteriorly and between the scapulae (over the main bronchus)
Bronchial
Expiratory sounds last longer than inspiratory ones.
Loud
Relatively high
Over the manubrium, if heard at all
Tracheal
Inspiratory and expiratory sounds are about equal.
Very loud
Relatively high
Over the trachea in the neck
*The thickness of the bars indicates intensity of breath sounds; the steeper their incline, the higher the pitch of the sounds.
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Table 21-5
• Abnormal (Adventitious) Breath Sounds
BREATH SOUND
Crackles Crackles in general Coarse crackles Fine crackles
Wheezes Sonorous wheezes (rhonchi) Sibilant wheezes
Friction rubs Pleural friction rub
DESCRIPTION
ETIOLOGY
Soft, high-pitched, discontinuous popping sounds that occur during inspiration
Secondary to fluid in the airways or alveoli or to opening of collapsed alveoli Associated with obstructive pulmonary disease
Discontinuous popping sounds heard in early inspiration; harsh, moist sound originating in the large bronchi Discontinuous popping sounds heard in late inspiration; sounds like hair rubbing together; originates in the alveoli
Associated with interstitial pneumonia, restrictive pulmonary disease (eg, fibrosis). Fine crackles in early inspiration are associated with bronchitis or pneumonia.
Deep, low-pitched rumbling sounds heard primarily during expiration; caused by air moving through narrowed tracheobronchial passages Continuous, musical, high-pitched, whistlelike sounds heard during inspiration and expiration caused by air passing through narrowed or partially obstructed airways; may clear with coughing
Secretions or tumor
Harsh, crackling sound, like two pieces of leather being rubbed together. Heard during inspiration alone or during both inspiration and expiration. May subside when patient holds breath. Coughing will not clear sound.
Secondary to inflammation and loss of lubricating pleural fluid
The physical findings for the most common respiratory diseases are summarized in Table 21-6.
PHYSICAL ASSESSMENT OF BREATHING ABILITY IN THE ACUTELY ILL PATIENT Tests of the patient’s breathing ability are easily performed at the bedside by measuring the respiratory rate (see the previous section “Breathing Patterns and Respiratory Rates”), tidal volume, minute ventilation, vital capacity, inspiratory force, and compliance. These tests are particularly important for patients at risk for developing pulmonary complications, including those who have undergone chest or abdominal surgery, have had prolonged anesthesia, have preexisting pulmonary disease, or are elderly. These tests are also used routinely for mechanically ventilated patients. Patients whose chest expansion is limited by external restrictions such as obesity or abdominal distention and who cannot breathe deeply because of postoperative pain or sedation will inhale and exhale a low volume of air (referred to as low tidal volumes). Prolonged hypoventilation at low tidal volumes can produce alveolar collapse or atelectasis. The amount of air remaining in the lungs after a normal expiration (functional residual capacity) falls, the ability of the lungs to expand (compliance) is reduced, and the patient must breathe faster to maintain the same degree of tissue oxygenation. These events can be exaggerated in patients who have preexisting pulmonary diseases and in elderly patients whose airways are less compliant, because the small airways may collapse during expiration.
!
Bronchospasm, asthma, and buildup of secretions
NURSING ALERT One should not rely only on visual inspection of the rate and depth of a patient’s respiratory excursions to determine the adequacy of ventilation. Respiratory excursions may appear normal or exaggerated due to an increased work of breathing, but the patient may actually be moving only enough air to ventilate the dead space. If there is any question regarding adequacy of ventilation, auscultation and/or pulse oximetry should be used for additional assessment of respiratory status.
Tidal Volume The volume of each breath is referred to as the tidal volume (see Table 21-1 to review lung capacities and volumes). A spirometer is an instrument that can be used at the bedside to measure volumes. If the patient is breathing through an endotracheal tube or tracheostomy, the spirometer is directly attached to it and the exhaled volume is obtained from the reading on the gauge. In other patients, the spirometer is attached to a facemask or a mouthpiece positioned so that it is airtight, and the exhaled volume is measured. The tidal volume may vary from breath to breath. To make the measurement reliable, it is important to measure the volumes of several breaths and to note the range of tidal volumes, together with the average tidal volume.
Minute Ventilation Respiratory rates and tidal volume alone are unreliable indicators of adequate ventilation because both can vary widely from breath to breath. Together, however, the tidal volume and respiratory
Chapter 21
Table 21-6
Assessment of Respiratory Function
483
• Assessment Findings in Common Respiratory Problems
PROBLEM
TACTILE FREMITUS
PERCUSSION
AUSCULTATION
Consolidation (eg, pneumonia)
Increased
Dull
Bronchitis
Normal
Resonant
Emphysema
Decreased
Hyperresonant
Asthma (severe attack)
Normal to decreased
Pulmonary edema
Normal
Resonant to hyperresonant Resonant
Bronchial breath sounds, crackles, bronchophony, egophony, whispered pectoriloquy Normal to decreased breath sounds, wheezes Decreased intensity of breath sounds, usually with prolonged expiration Wheezes
Pleural effusion
Absent
Dull to flat
Pneumothorax Atelectasis
Decreased Absent
Hyperresonant Flat
Crackles at lung bases, possibly wheezes Decreased to absent breath sounds, bronchial breath sounds and bronchophony, egophony, and whispered pectoriloquy above the effusion over the area of compressed lung Absent breath sounds Decreased to absent breath sounds
rate are important because the minute ventilation, which is useful in detecting respiratory failure, can be determined from them. Minute ventilation is the volume of air expired per minute. It is equal to the product of the tidal volume and the respiratory rate or frequency. In practice, the minute ventilation is not calculated but is measured directly using a spirometer. Minute ventilation may be decreased by a variety of conditions that result in hypoventilation. When the minute ventilation falls, alveolar ventilation in the lungs also decreases, and the PaCO2 increases. Risk factors for hypoventilation are listed in Chart 21-8.
useful in the unconscious patient. The equipment needed for this measurement includes a manometer that measures negative pressure and adapters that are connected to an anesthesia mask or a cuffed endotracheal tube. The manometer is attached and the airway is completely occluded for 10 to 20 seconds while the inspiratory efforts of the patient are registered on the manometer. The normal inspiratory pressure is about 100 cm H2O. If the negative pressure registered after 15 seconds of occluding the airway is less than about 25 cm H2O, mechanical ventilation is usually required because the patient lacks sufficient muscle strength for deep breathing or effective coughing.
Vital Capacity
Diagnostic Evaluation
Vital capacity is measured by having the patient take in a maximal breath and exhale fully through a spirometer. The normal value depends on the patient’s age, gender, body build, and weight.
A wide range of diagnostic studies, described on the following pages, may be performed in patients with respiratory conditions.
!
NURSING ALERT Most patients can generate a vital capacity twice the volume they normally breathe in and out (tidal volume). If the vital capacity is less than 10 mL/kg, the patient will be unable to sustain spontaneous ventilation and will require respiratory assistance.
When the vital capacity is exhaled at a maximal flow rate, the forced vital capacity is measured. Most patients can exhale at least 80% of their vital capacity in 1 second (forced expiratory volume in 1 second, or FEV1) and almost all of it in 3 seconds (FEV3 ). A reduction in FEV1 suggests abnormal pulmonary air flow. If the patient’s FEV1 and forced vital capacity are proportionately reduced, maximal lung expansion is restricted in some way. If the reduction in FEV1 greatly exceeds the reduction in forced vital capacity, the patient may have some degree of airway obstruction.
Inspiratory Force Inspiratory force evaluates the effort the patient is making during inspiration. It does not require patient cooperation and thus is
PULMONARY FUNCTION TESTS Pulmonary function tests (PFTs) are routinely used in patients with chronic respiratory disorders. They are performed to assess respiratory function and to determine the extent of dysfunction. Such tests include measurements of lung volumes, ventilatory
Chart 21-8
Risk Factors for Hypoventilation • Limited neurologic impulses transmitted from the brain to the respiratory muscles, as in spinal cord trauma, cerebrovascular accidents, tumors, myasthenia gravis, Guillain-Barré syndrome, polio, and drug overdose • Depressed respiratory centers in the medulla, as with anesthesia and drug overdose • Limited thoracic movement (kyphoscoliosis), limited lung movement (pleural effusion, pneumothorax), or reduced functional lung tissue (chronic pulmonary diseases, severe pulmonary edema)
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function, and the mechanics of breathing, diffusion, and gas exchange (Table 21-7). PFTs are useful in following the course of a patient with an established respiratory disease and assessing the response to therapy. They are useful as screening tests in potentially hazardous industries, such as coal mining and those that involve exposure to asbestos and other noxious fumes, dusts, or gases. They are useful for screening patients scheduled for thoracic and upper abdominal surgery, and symptomatic patients with a history suggesting high risk. PFTs generally are performed by a technician using a spirometer that has a volume-collecting device attached to a recorder that demonstrates volume and time simultaneously. A number of tests are carried out because no single measurement provides a complete picture of pulmonary function. The most frequently used PFTs are described in Table 21-7. Technology is available that allows for more complex assessment of pulmonary function. Methods include exercise tidal flow-volume loops, negative expiratory pressure, nitric oxide, and forced oscillation. These assessment methods allow for detailed evaluation of expiratory flow limitations and airway inflammation (Johnson, Beck, Zeballos & Weisman, 1999). PFT results are interpreted on the basis of the degree of deviation from normal, taking into consideration the patient’s height, weight, age, and gender. Because there is a wide range of normal values, PFTs may not detect early localized changes. The patient with respiratory symptoms (dyspnea, wheezing, cough, sputum production) usually undergoes a complete diagnostic evaluation, even though the results of PFTs are “normal.” Trends of results provide information about disease progression as well as the patient’s response to therapy. Patients with respiratory disorders may be taught how to measure their peak flow rate (reflects maximal expiratory flow) at home using a spirometer. This allows them to monitor the progress of therapy, to alter medications and other interventions as needed based on caregiver guidelines, or to notify the health care provider if there is inadequate response to their own interventions. Home care teaching instructions are described in Chapter 24, which discusses asthma.
Table 21-7
ARTERIAL BLOOD GAS STUDIES Measurements of blood pH and of arterial oxygen and carbon dioxide tensions are obtained when managing patients with respiratory problems and in adjusting oxygen therapy as needed. The arterial oxygen tension (PaO2) indicates the degree of oxygenation of the blood, and the arterial carbon dioxide tension (PaCO2) indicates the adequacy of alveolar ventilation. Arterial blood gas studies aid in assessing the ability of the lungs to provide adequate oxygen and remove carbon dioxide and the ability of the kidneys to reabsorb or excrete bicarbonate ions to maintain normal body pH. Serial blood gas analysis also is a sensitive indicator of whether the lung has been damaged after chest trauma. Arterial blood gas levels are obtained through an arterial puncture at the radial, brachial, or femoral artery or through an indwelling arterial catheter. Arterial blood gas levels are discussed in detail in Chapter 14.
PULSE OXIMETRY Pulse oximetry is a noninvasive method of continuously monitoring the oxygen saturation of hemoglobin (SpO2 or SaO2). Although pulse oximetry does not replace arterial blood gas measurement, it is an effective tool to monitor for subtle or sudden changes in oxygen saturation. It is used in all settings where oxygen saturation monitoring is needed, such as the home, clinics, ambulatory surgical settings, and hospitals. A probe or sensor is attached to the fingertip (Fig. 21-14), forehead, earlobe, or bridge of the nose. The sensor detects changes in oxygen saturation levels by monitoring light signals generated by the oximeter and reflected by blood pulsing through the tissue at the probe. Normal SpO2 values are 95% to 100%. Values less than 85% indicate that the tissues are not receiving enough oxygen, and the patient needs further evaluation. SpO2 values obtained by pulse oximetry are unreliable in cardiac arrest and shock, when dyes (ie, methylene blue) or vasoconstrictor medications have been used, or when the patient has severe anemia or a high carbon monoxide level.
• Pulmonary Function Tests
TERM USED
SYMBOL
DESCRIPTION
REMARKS
Forced vital capacity
FVC
Forced expiratory volume (qualified by subscript indicating the time intervals in seconds) Ratio of timed forced expiratory volume to forced vital capacity Forced expiratory flow
FEVt , usually FEV1
Vital capacity performed with a maximally forced expiratory effort Volume of air exhaled in the specified time during the performance of forced vital capacity; FEV1 is volume exhaled in 1 second FEVt expressed as a percentage of the forced vital capacity
Forced vital capacity is often reduced in COPD because of air trapping. A valuable clue to the severity of the expiratory airway obstruction
Mean forced expiratory flow between 200 and 1,200 mL of the FVC Mean forced expiratory flow during the middle half of the FVC Mean forced expiratory flow during the terminal portion of the FVC Volume of air expired in a specified period (12 seconds) during repetitive maximal effort
An indicator of large airway obstruction
1
FEVt /FVC%, usually FEV1/FVC% FEF200–1200
Forced midexpiratory flow
FEF25%–75%
Forced end expiratory flow
FEF75%–85%
Maximal voluntary ventilation
MVV
Another way of expressing the presence or absence of airway obstruction
Slowed in small airway obstruction Slowed in obstruction of smallest airways An important factor in exercise tolerance
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IMAGING STUDIES Imaging studies, including x-rays, computed tomography (CT) scans, magnetic resonance imaging (MRI), contrast studies, and radioisotope diagnostic scans may be part of any diagnostic workup, ranging from a determination of the extent of infection in sinusitis to tumor growth in cancer.
Chest X-Ray
FIGURE 21-14 Measuring blood oxygenation with pulse oximetry reduces the need for invasive procedures, such as drawing blood for analysis of oxygen levels. After the pulse oximeter sensor slips easily over a patient’s finger, the oxygen saturation level appears on the monitor. The oximeter is portable and ideal for home use. Courtesy Novametrix Medical Systems, Inc.
CULTURES Throat cultures may be performed to identify organisms responsible for pharyngitis. Throat culture may also assist in identifying organisms responsible for infection of the lower respiratory tract. Nasal swabs also may be performed for the same purpose.
SPUTUM STUDIES Sputum is obtained for analysis to identify pathogenic organisms and to determine whether malignant cells are present. It also may be used to assess for hypersensitivity states (in which there is an increase in eosinophils). Periodic sputum examinations may be necessary for patients receiving antibiotics, corticosteroids, and immunosuppressive medications for prolonged periods because these agents are associated with opportunistic infections. In general, sputum cultures are used in diagnosis, for drug sensitivity testing, and to guide treatment. Expectoration is the usual method for collecting a sputum specimen. The patient is instructed to clear the nose and throat and rinse the mouth to decrease contamination of the sputum. After taking a few deep breaths, the patient coughs (rather than spits), using the diaphragm, and expectorates into a sterile container. If the sputum cannot be raised spontaneously, the patient often can be induced to cough deeply by breathing an irritating aerosol of supersaturated saline, propylene glycol, or some other agent delivered with an ultrasonic nebulizer. Other methods of collecting sputum specimens include endotracheal aspiration, bronchoscopic removal, bronchial brushing, transtracheal aspiration, and gastric aspiration—usually for tuberculosis organisms (see Chap. 23). Generally, the deepest specimens (those from the base of the lungs) are obtained in the early morning after they have accumulated overnight. The specimen is delivered to the laboratory within 2 hours by the patient or nurse. Allowing the specimen to stand for several hours in a warm room results in the overgrowth of contaminant organisms and may make it difficult to identify the organisms (especially Mycobacterium tuberculosis). The home care nurse may assist patients who need help obtaining the sample or who cannot deliver the specimen to the laboratory in a timely fashion.
Normal pulmonary tissue is radiolucent; therefore, densities produced by fluid, tumors, foreign bodies, and other pathologic conditions can be detected by x-ray examination. A chest x-ray may reveal an extensive pathologic process in the lungs in the absence of symptoms. The routine chest x-ray consists of two views—the posteroanterior projection and the lateral projection. Chest x-rays are usually taken after full inspiration (a deep breath) because the lungs are best visualized when they are well aerated. Also, the diaphragm is at its lowest level and the largest expanse of lung is visible. If taken on expiration, x-ray films may accentuate an otherwise unnoticed pneumothorax or obstruction of a major artery.
Computed Tomography CT is an imaging method in which the lungs are scanned in successive layers by a narrow-beam x-ray. The images produced provide a cross-sectional view of the chest. Whereas a chest x-ray shows major contrast between body densities, such as bones, soft tissues, and air, CT scans can distinguish fine tissue density. CT may be used to define pulmonary nodules and small tumors adjacent to pleural surfaces that are not visible on routine chest x-ray, and to demonstrate mediastinal abnormalities and hilar adenopathy, which are difficult to visualize with other techniques. Contrast agents are useful when evaluating the mediastinum and its contents.
Magnetic Resonance Imaging MRIs are similar to CT scans except that magnetic fields and radiofrequency signals are used instead of a narrow-beam x-ray. MRIs yield a much more detailed diagnostic image than CT scans. MRI is used to characterize pulmonary nodules, stage bronchogenic carcinoma (assessment of chest wall invasion), and evaluate inflammatory activity in interstitial lung disease, acute pulmonary embolism, and chronic thrombolytic pulmonary hypertension (Kauczor & Kreitner, 2000).
Fluoroscopic Studies Fluoroscopy is used to assist with invasive procedures, such as a chest needle biopsy or transbronchial biopsy, performed to identify lesions. It also may be used to study the movement of the chest wall, mediastinum, heart, and diaphragm, to detect diaphragm paralysis, and to locate lung masses.
Pulmonary Angiography Pulmonary angiography is most commonly used to investigate thromboembolic disease of the lungs, such as pulmonary emboli and congenital abnormalities of the pulmonary vascular tree. It involves the rapid injection of a radiopaque agent into the vasculature of the lungs for radiographic study of the pulmonary vessels.
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It can be performed by injecting the radiopaque agent into a vein in one or both arms (simultaneously) or into the femoral vein, with a needle or catheter. The agent also can be injected into a catheter that has been inserted in the main pulmonary artery or its branches or into the great veins proximal to the pulmonary artery.
Radioisotope Diagnostic Procedures (Lung Scans) Several types of lung scans—ventilation-perfusion scan, gallium scan, and positron emission tomography—are used to detect normal lung functioning, pulmonary vascular supply, and gas exchange. A ventilation-perfusion lung scan is first performed by injecting a radioactive agent into a peripheral vein and then obtaining a scan of the chest to detect radiation. The isotope particles pass through the right side of the heart and are distributed into the lungs in amounts proportional to the regional blood flow, making it possible to trace and measure blood perfusion through the lung. This procedure is used clinically to measure the integrity of the pulmonary vessels relative to blood flow and to evaluate blood flow abnormalities, as seen in pulmonary emboli. The imaging time is 20 to 40 minutes, during which the patient will lie under the camera with a mask fitted over the nose and mouth. This is followed by the ventilation component of the scan. The patient takes a deep breath of a mixture of oxygen and radioactive gas, which diffuses throughout the lungs. A scan is performed to detect ventilation abnormalities in patients who have regional differences in ventilation. It may be helpful in the diagnosis of bronchitis, asthma, inflammatory fibrosis, pneumonia, emphysema, and lung cancer. Ventilation without perfusion is seen with pulmonary emboli. A gallium scan is a radioisotope lung scan used to detect inflammatory conditions, abscesses, adhesions, and the presence, location, and size of tumors. It is used to stage bronchogenic cancer and record tumor regression after chemotherapy or radiation. Gallium is injected intravenously, and scans are taken at 6, 24, and/or 48 hours to evaluate gallium uptake by the pulmonary tissues. Positron emission tomography (PET) is a radioisotope study with advanced diagnostic capabilities. It is used to evaluate lung nodules for malignancy. PET scans can detect and display metabolic changes in tissue, distinguish normal tissue from tissues that are diseased (such as in cancer), differentiate viable from dead or dying tissue, show regional blood flow, and determine the distribution and fate of medications in the body (Shuster, 1998). PET scans are more accurate in detecting malignancies than CT scans (Coleman, 1999; Graeber, Gupta & Murray, 1999) and have equivalent accuracy in detecting malignant nodules when compared to invasive procedures such as thoracoscopy (Lowe, Fletcher, Gobar et al., 1998).
ENDOSCOPIC PROCEDURES Bronchoscopy Bronchoscopy is the direct inspection and examination of the larynx, trachea, and bronchi through either a flexible fiberoptic bronchoscope or a rigid bronchoscope. The fiberoptic scope is used more frequently in current practice.
The purposes of diagnostic bronchoscopy are: (1) to examine tissues or collect secretions, (2) to determine the location and extent of the pathologic process and to obtain a tissue sample for diagnosis (by biting or cutting forceps, curettage, or brush biopsy), (3) to determine if a tumor can be resected surgically, and (4) to diagnose bleeding sites (source of hemoptysis). Therapeutic bronchoscopy is used to: (1) remove foreign bodies from the tracheobronchial tree, (2) remove secretions obstructing the tracheobronchial tree when the patient cannot clear them, (3) treat postoperative atelectasis, and (4) destroy and excise lesions. The fiberoptic bronchoscope is a thin, flexible bronchoscope that can be directed into the segmental bronchi (Fig. 21-15). Because of its small size, its flexibility, and its excellent optical system, it allows increased visualization of the peripheral airways and is ideal for diagnosing pulmonary lesions. Fiberoptic bronchoscopy allows biopsy of previously inaccessible tumors and can be performed at the bedside. It also can be performed through endotracheal or tracheostomy tubes of patients on ventilators. Cytologic examinations can be performed without surgical intervention. The rigid bronchoscope is a hollow metal tube with a light at its end. It is used mainly for removing foreign substances, investigating the source of massive hemoptysis, or performing endobronchial surgical procedures. Rigid bronchoscopy is performed in the operating room, not at the bedside. Possible complications of bronchoscopy include a reaction to the local anesthetic, infection, aspiration, bronchospasm, hypoxemia (low blood oxygen level), pneumothorax, bleeding, and perforation. NURSING INTERVENTIONS Before the procedure, a signed consent form is obtained from the patient, and food and fluids are withheld for 6 hours before the test to reduce the risk of aspiration when the cough reflex is blocked by anesthesia. The nurse explains the procedure to the patient to reduce fear and decrease anxiety and administers preoperative medications (usually atropine and a sedative or opioid) as prescribed to inhibit vagal stimulation (thereby guarding against bradycardia, dysrhythmias, and hypotension), suppress the cough reflex, sedate the patient, and relieve anxiety.
!
NURSING ALERT Sedation given to patients with respiratory insufficiency may precipitate respiratory arrest.
The patient must remove dentures and other oral prostheses. The examination is usually performed under local anesthesia, but general anesthesia may be needed for rigid bronchoscopy. A topical anesthetic such as lidocaine (Xylocaine) may be sprayed on the pharynx or dropped on the epiglottis and vocal cords and into the trachea to suppress the cough reflex and minimize discomfort. Sedatives or opioids are administered intravenously as prescribed to provide moderate sedation. After the procedure, it is important that the patient takes nothing by mouth until the cough reflex returns, because the preoperative sedation and local anesthesia impair the protective laryngeal reflex and swallowing for several hours. Once the patient demonstrates a cough reflex, the nurse may offer ice chips and eventually fluids. The nurse assesses for confusion and lethargy in the elderly, which may be due to the large doses of lidocaine given during the procedure. The nurse also monitors the patient’s res-
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Fiberoptic bronchoscope
Smaller bronchus
FIGURE 21-15 Endoscopic bronchoscopy permits visualization of bronchial structures. The bronchoscope is advanced into bronchial structures orally. Bronchoscopy permits the clinician not only to diagnose but also to treat various lung problems.
piratory status and observes for hypoxia, hypotension, tachycardia, dysrhythmias, hemoptysis, and dyspnea. Any abnormality is reported promptly. The patient is not discharged from the recovery area until adequate cough reflex and respiratory status are present. The nurse instructs the patient and family caregivers to report any shortness of breath or bleeding immediately.
Thoracoscopy Thoracoscopy is a diagnostic procedure in which the pleural cavity is examined with an endoscope (Fig. 21-16). Small incisions are made into the pleural cavity in an intercostal space; the location of the incision depends on the clinical and diagnostic findings. After any fluid present in the pleural cavity is aspirated, the fiberoptic mediastinoscope is inserted into the pleural cavity, and its surface is inspected through the instrument. After the procedure, a chest tube may be inserted, and the pleural cavity is drained by negative-pressure water-seal drainage. Thoracoscopy is primarily indicated in the diagnostic evaluation of pleural effusions, pleural disease, and tumor staging. Biopsies of the lesions can be performed under visualization for diagnosis. Thoracoscopic procedures have expanded with the availability of video monitoring, which permits improved visualization of the lung. Such procedures also have been used with the carbon dioxide laser in the removal of pulmonary blebs and bullae and in the treatment of spontaneous pneumothorax. Lasers have also
FIGURE 21-16 Endoscopic thoracoscopy. Like bronchoscopy, thoracoscopy uses fiberoptic instruments and video cameras for visualizing thoracic structures. Unlike bronchoscopy, thoracoscopy usually requires the surgeon to make a small incision before inserting the endoscope. A combined diagnostic–treatment procedure, thoracoscopy includes excising tissue for biopsy.
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been used in the excision of peripheral pulmonary nodules. Although the laser does not replace the need for thoracotomy in the treatment of some lung cancers, its use continues to expand because it is less invasive. NURSING INTERVENTIONS Follow-up care in the health care facility and at home involves monitoring the patient for shortness of breath (which might indicate a pneumothorax), and minor activity restrictions, which vary depending on the intensity of the procedure. If a chest tube is in place, monitoring the chest drainage system and chest tube insertion site is essential (see Chap. 25).
THORACENTESIS A thin layer of pleural fluid normally remains in the pleural space. An accumulation of pleural fluid may occur with some disorders. A sample of this fluid can be obtained by thoracentesis (aspiration of pleural fluid for diagnostic or therapeutic purposes). It is important to position the patient as shown in Chart 21-9. A needle biopsy of the pleura may be performed at the same time. Studies of pleural fluid include Gram’s stain culture and sensitivity, acid-fast staining and culture, differential cell count, cytology, pH, specific gravity, total protein, and lactic dehydrogenase.
BIOPSY Biopsy, the excision of a small amount of tissue, may be performed to permit examination of cells from the pharynx, larynx, and nasal passages. Local, topical, or general anesthesia may be administered, depending on the site and the procedure (see also “Lung Biopsy Procedures” below).
Pleural Biopsy Pleural biopsy is accomplished by needle biopsy of the pleura or by pleuroscopy, a visual exploration through a fiberoptic bronchoscope inserted into the pleural space. Pleural biopsy is performed when there is pleural exudate of undetermined origin and when there is a need to culture or stain the tissue to identify tuberculosis or fungi.
Lung Biopsy Procedures When the chest x-ray findings are inconclusive or show pulmonary density (indicating an infiltrate or lesion), biopsy may be performed to obtain lung tissue for examination to identify the nature of the lesion. There are several nonsurgical lung biopsy techniques that are used because they yield accurate information with low morbidity: (1) transcatheter bronchial brushing, (2) transbronchial lung biopsy, or (3) percutaneous (through-the-skin) needle biopsy. In transcatheter bronchial brushing, a fiberoptic bronchoscope is introduced into the bronchus under fluoroscopy. A small brush attached to the end of a flexible wire is inserted through the bronchoscope. Under direct visualization, the area under suspicion is brushed back and forth, causing cells to slough off and adhere to the brush. The catheter port of the bronchoscope may be used to irrigate the lung tissue with saline solution to secure material for additional studies. The brush is removed from the bronchoscope and a microscopic slide is made. The brush may be cut off and sent to the pathology laboratory for analysis.
This procedure is useful for cytologic evaluations of lung lesions and for the identification of pathogenic organisms (Nocardia, Aspergillus, Pneumocystis carinii, and other pathogens). It is especially useful in the immunologically compromised patient. A transbronchial lung biopsy uses biting or cutting forceps introduced by a fiberoptic bronchoscope. A biopsy is indicated when a lung lesion is suspected and the results of routine sputum samples and bronchoscopic washings are negative. Another method of bronchial brushing involves the introduction of the catheter through the transcricothyroid membrane by needle puncture. After this procedure, the patient is instructed to hold a finger or thumb over the puncture site while coughing to prevent air from leaking into the surrounding tissues. Percutaneous needle biopsy may be accomplished with a cutting needle or by aspiration with a spinal-type needle that provides a tissue specimen for histologic study. Analgesia may be administered before the procedure. The skin over the biopsy site is cleansed and anesthetized and a small incision is made. The biopsy needle is inserted through the incision into the pleura with the patient holding the breath in mid-expiration. Using fluoroscopic monitoring, the surgeon guides the needle into the periphery of the lesion and obtains a tissue sample from the mass. Possible complications include pneumothorax, pulmonary hemorrhage, and empyema. NURSING INTERVENTIONS After the procedure, recovery and home care are similar to those for bronchoscopy and thoracoscopy. Nursing care involves monitoring the patient for shortness of breath, bleeding, and infection. In preparation for discharge, the patient and/or family is instructed to report pain, shortness of breath, visible bleeding, or redness of the biopsy site or pus to the health care provider immediately. Patients who have undergone biopsy are often anxious because of the need for the biopsy and the potential findings; the nurse must consider this in providing postbiopsy care and teaching.
Lymph Node Biopsy The scalene lymph nodes are enmeshed in the deep cervical pad of fat overlying the scalenus anterior muscle. They drain the lungs and mediastinum and may show histologic changes from intrathoracic disease. When these nodes are palpable on physical examination, a scalene node biopsy may be performed. A biopsy of these nodes may be performed to detect lymph node spread of pulmonary disease and to establish a diagnosis or prognosis in such diseases as Hodgkin’s disease, sarcoidosis, fungal disease, tuberculosis, and carcinoma. Mediastinoscopy is the endoscopic examination of the mediastinum for exploration and biopsy of mediastinal lymph nodes that drain the lungs; this examination does not require a thoracotomy. Biopsy is usually performed through a suprasternal incision. Mediastinoscopy is carried out to detect mediastinal involvement of pulmonary malignancy and to obtain tissue for diagnostic studies of other conditions (eg, sarcoidosis). An anterior mediastinotomy is thought to provide better exposure and diagnostic possibilities than a mediastinoscopy. An incision is made in the area of the second or third costal cartilage. The mediastinum is explored and biopsies are performed on any lymph nodes found. Chest tube drainage is required after the procedure. Mediastinotomy is particularly valuable to determine whether a pulmonary lesion is resectable.
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Chart 21-9 GUIDELINES FOR Assisting the Patient Undergoing Thoracentesis A thoracentesis (aspiration of fluid or air from the pleural space) is performed on patients with various clinical problems. A diagnostic or therapeutic procedure, thoracentesis may be used for: • Removal of fluid and air from the pleural cavity • Aspiration of pleural fluid for analysis • Pleural biopsy • Instillation of medication into the pleural space The responsibilities of the nurse and rationale for the nursing actions are summarized below. NURSING ACTIVITIES 1. Ascertain in advance that a chest x-ray has been ordered and completed and the consent form has been signed.
2. Assess the patient for allergy to the local anesthetic to be used. Administer sedation if prescribed. 3. Inform the patient about the nature of the procedure and: a. The importance of remaining immobile b. Pressure sensations to be experienced c. That minimal discomfort is anticipated after the procedure 4. Position the patient comfortably with adequate supports. If possible, place the patient upright or in one of the following positions: a. Sitting on the edge of the bed with the feet supported and arms and head on a padded over-the-bed table
RATIONALE 1. Posteroanterior and lateral chest x-ray films are used to localize fluid and air in the pleural cavity and to aid in determining the puncture site. When fluid is loculated (isolated in a pocket of pleural fluid), ultrasound scans are performed to help select the best site for needle aspiration. 2. If the patient is allergic to the initially prescribed anesthetic, assessment findings provide an opportunity to use a safer anesthetic. 3. An explanation helps to orient the patient to the procedure, assists the patient to mobilize resources, and provides an opportunity to ask questions and verbalize anxiety. 4. The upright position facilitates the removal of fluid that usually localizes at the base of the chest. A position of comfort helps the patient to relax.
Patient positioned for thoracentesis.
b. Straddling a chair with arms and head resting on the back of the chair c. Lying on the unaffected side with the bed elevated 30 degrees to 45 degrees if unable to assume a sitting position 5. Support and reassure the patient during the procedure. a. Prepare the patient for the cold sensation of skin germicide solution and for a pressure sensation from infiltration of local anesthetic agent. b. Encourage the patient to refrain from coughing.
5. Sudden and unexpected movement, such as coughing, by the patient can traumatize the visceral pleura and lung.
(continued)
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Chart 21-9 GUIDELINES FOR Assisting the Patient Undergoing Thoracentesis (Continued) NURSING ACTIVITIES 6. Expose the entire chest. The site for aspiration is visualized by chest x-ray film and percussion. If fluid is in the pleural cavity, the thoracentesis site is determined by the chest x-ray, ultrasound scanning, and physical findings, with attention to the site of maximal dullness on percussion. 7. The procedure is performed under aseptic conditions. After the skin is cleansed, the physician uses a small-caliber needle to inject a local anesthetic slowly into the intercostal space. 8. The physician advances the thoracentesis needle with the syringe attached. When the pleural space is reached, suction may be applied with the syringe. a. A 20-mL syringe with a three-way stopcock is attached to the needle (one end of the adapter is attached to the needle and the other to the tubing leading to a receptacle that receives the fluid being aspirated). b. If a considerable quantity of fluid is removed, the needle is held in place on the chest wall with a small hemostat. 9. After the needle is withdrawn, pressure is applied over the puncture site and a small, sterile dressing is fixed in place. 10. Advise the patient that he or she will be on bed rest and a chest x-ray will be obtained after thoracentesis. 11. Record the total amount of fluid withdrawn from the procedure and document the nature of the fluid, its color, and its viscosity. If indicated, prepare samples of fluid for laboratory evaluation. A specimen container with formalin may be needed for a pleural biopsy. 12. Monitor the patient at intervals for increasing respiratory rate; asymmetry in respiratory movement; faintness; vertigo; tightness in chest; uncontrollable cough; blood-tinged, frothy mucus; a rapid pulse; and signs of hypoxemia.
NURSING INTERVENTIONS Postprocedure care focuses on providing adequate oxygenation, monitoring for bleeding, and providing pain relief. The patient may be discharged a few hours after the chest drainage system is removed. The nurse should instruct the patient and family about monitoring for changes in respiratory status, taking into consideration the impact of anxiety about the potential findings of the biopsy on their ability to remember those instructions.
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Critical Thinking Exercises
1.
After a transbronchial lung biopsy, your patient reports shortness of breath and appears anxious. He is coughing up blood-tinged sputum. Based on your knowledge of the risks associated with lung biopsy, how would you focus your assessment? What physical and psychological nursing interventions would be appropriate for the patient at this time?
2.
Your patient is scheduled for a video-assisted thoracoscopy. Describe the postprocedure nursing care and teaching for a patient undergoing this procedure. Identify the specific assessment parameters that are indicated.
RATIONALE 6. If air is in the pleural cavity, the thoracentesis site is usually in the second or third intercostal space in the midclavicular line because air rises in the thorax. 7. An intradermal wheal is raised slowly; rapid injection causes pain. The parietal pleura is very sensitive and should be well infiltrated with anesthetic before the physician passes the thoracentesis needle through it.
a. When a large quantity of fluid is withdrawn, a three-way stopcock serves to keep air from entering the pleural cavity. b. The hemostat steadies the needle on the chest wall. Sudden pleuritic chest pain or shoulder pain may indicate that the needle point is irritating the visceral or the diaphragmatic pleura. 9. Pressure helps to stop bleeding and the dressing protects the site. 10. A chest x-ray verifies that there is no pneumothorax. 11. The fluid may be clear, serous, bloody, purulent, etc.
12. Pneumothorax, tension pneumothorax, subcutaneous emphysema, or pyrogenic infection are complications of a thoracentesis. Pulmonary edema or cardiac distress can occur after a sudden shift in mediastinal contents when large amounts of fluid are aspirated.
3.
Your patient has had a thoracentesis to remove pleural fluid for laboratory analysis and to relieve shortness of breath. What assessment should be carried out following the procedure? What teaching is warranted for the patient and family if she is to be discharged an hour after the procedure? How would you modify your instructions to the patient if she lives alone?
4.
Your frail, elderly patient has a diagnosis of long-standing cardiac disease and is scheduled for PFTs prior to surgery to repair her cardiac valves. What specific explanations about the tests would you provide to the patient? What problems would you monitor for following the PFT?
REFERENCES AND SELECTED READINGS Books Bickley, L. S. (2003). Bates’ guide to physical examination and history taking (8th ed.). Philadelphia: Lippincott Williams & Wilkins. Blair, K. A. (1999). The aging pulmonary system. In M. Stanley & P. G. Bear (Eds.), Gerontological nursing (2d ed.). Philadelphia: F. A. Davis. Levitzky, M. G. (1999). Pulmonary physiology (4th ed.). New York: McGraw Hill.
Chapter 21 Sole, M. L., & Byers, J. F. (2001). Ventilatory assistance. In M. L. Sole, J. C. Hartshorn, & M. L. Lamborn (Eds.), Introduction to critical care nursing (3rd ed.). Philadelphia: W. B. Saunders. West, J. B. (2000). Respiratory physiology: The essentials. Philadelphia: Lippincott Williams & Wilkins. West, J. B. (2001). Pulmonary physiology and pathophysiology: An integrated, case-based approach. Philadelphia: Lippincott Williams & Wilkins. Wilkins, R. L., Sheldon, R. L., & Knider, S. J. (2000). Clinical assessment in respiratory care (4th ed.). St. Louis: Mosby-Year Book.
Journals Asterisks indicate nursing research articles. Boyle, A. H., & Waters, H. F. (2000). Issues in respiratory nursing: Focus on prevention: recommendations of the National Lung Health Education Program. Heart & Lung, 29(6), 446–449. Camhi, S. L., & Enright, P. L. (2000). How to assess pulmonary function in older persons. Journal of Respiratory Diseases, 21(6), 395–399. Coleman, R. E. (1999). PET in lung cancer. Journal of Nuclear Medicine, 40(5), 814–820. Graeber, G. M., Gupta, N. C., & Murray, G. F. (1999). Positron emission tomographic imaging with fluorodeoxyglucose is efficacious in evaluating malignant pulmonary disease. Journal of Thoracic and Cardiovascular Surgery, 117(4), 719–727. Horne, C., & Derrico, D. (1999). Mastering ABGs. The art of arterial blood gas measurement. American Journal of Nursing, 99(8), 26–32. Janssens, J. P., de Muralt, B., & Titelion, V. (2000). Management of dyspnea in severe chronic obstructive pulmonary disease. Journal of Pain and Symptom Management, 19(5), 378–392. Johnson, B. D., Beck, K. C., Zeballos, R. J., & Weisman, I. M. (1999). Advances in pulmonary laboratory testing. Chest, 116(5), 1377–1387.
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Kauczor, H. U., & Kreitner, K. E. (2000). Contrast-enhanced MRI of the lung. European Journal of Radiology, 34(3), 196–207. Lowe, V. J., Fletcher, J. W., Gobar, L., Lawson, M., et al. (1998). Prospective investigation of positron emission tomography in lung nodules. Journal of Clinical Oncology, 16(3), 1075–1084. Martin, B., Llewellyn, J., Faut-Callahan, M., & Meyer, P. (2000). The use of telemetric oximetry in the clinical setting. MedSurg Nursing, 9(2), 71–76. *Nield, M. (2000). Dyspnea self-management in African Americans with chronic lung disease. Heart & Lung, 29(1), 50–55. Salzman, S. (1999). Pulmonary function testing: Tips on how to interpret the results. Journal of Respiratory Diseases, 20(12), 809–812. Shortall, S. P., & Perkins, L. A. (1999). Interpreting the ins and outs of pulmonary function tests. Nursing, 29(12), 41–47. Shuster, D. P. (1998). The evaluation of lung function with PET. Seminars in Nuclear Medicine, 28(4), 341–351. Wong, F. W. H. (1999). A new approach to ABG interpretation. American Journal of Nursing, 99(8), 34–36.
RESOURCES AND WEBSITES American Lung Association, 1740 Broadway, New York, NY 10019; (212) 315-8700; 1-800-LUNG USA; http://www.lungusa.org. American Association for Respiratory Care, 11030 Ables Lane, Dallas, TX 75229; (972) 243-2272; http://www.aarc.org. National Heart, Lung, and Blood Institute/National Institutes of Health, Rockville Pike, Bldg. 31, Bethesda, MD 20892; (301) 4965166; http://www.nhlbi.nih.gov/nhlbi/index.htm. National Lung Health Education Program: http://www.nlhep.org. Has easy-to-read teaching resources for patients.
Chapter
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Management of Patients With Upper Respiratory Tract Disorders
LEARNING OBJECTIVES
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On completion of this chapter, the learner will be able to: 1. Describe nursing management of patients with upper airway 2. 3. 4. 5.
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disorders. Compare and contrast the upper respiratory tract infections with regard to cause, incidence, clinical manifestations, management, and the significance of preventive health care. Use the nursing process as a framework for care of patients with upper airway infection. Describe nursing management of the patient with epistaxis. Use the nursing process as a framework for care of patients undergoing laryngectomy.
M
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any upper airway disorders are relatively minor, and their effects are limited to mild and temporary discomfort and inconvenience for the patient. However, other upper airway disorders are acute, severe, and life-threatening and may require permanent alterations in breathing and speaking. Thus, the nurse must have good assessment skills, an understanding of the wide variety of disorders that may affect the upper airway, and an awareness of the impact of these alterations on patients. Because many of the disorders are treated outside the hospital or at home by patients themselves, patient teaching is an important aspect of nursing care. When caring for patients with acute, life-threatening disorders, the nurse needs highly developed assessment and clinical management skills, along with a focus on rehabilitation needs.
Upper Airway Infections Upper airway infections are common conditions that affect most people on occasion. Some infections are acute, with symptoms that last several days; others are chronic, with symptoms that last a long time or recur. Patients with these conditions seldom require hospitalization. However, nurses working in community settings or long-term care facilities may encounter patients who have these infections. Thus, it is important for the nurse to recognize the signs and symptoms and to provide appropriate care.
RHINITIS Rhinitis is a group of disorders characterized by inflammation and irritation of the mucous membranes of the nose. It may be classified as nonallergic or allergic. It is estimated that 10% to 15% of the population of the United States has allergic rhinitis (Middleton et al., 1998). Rhinitis may be an acute or chronic condition.
Pathophysiology Nonallergic rhinitis may be caused by a variety of factors, including environmental factors such as changes in temperature or humidity, odors, or foods; infection; age; systemic disease; drugs (cocaine) or prescribed medications; or the presence of a foreign body. Drug-induced rhinitis is associated with use of antihypertensive agents and oral contraceptives and chronic use of nasal decongestants. Rhinitis also may be a manifestation of an allergy (see Chap. 53), in which case it is referred to as allergic rhinitis. Figure 22-1 shows the pathological processes involved in rhinitis and sinusitis.
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Clinical Manifestations The signs and symptoms of rhinitis include rhinorrhea (excessive nasal drainage, runny nose), nasal congestion, nasal discharge (purulent with bacterial rhinitis), nasal itchiness, and sneezing. Headache may occur, particularly if sinusitis is also present.
Medical Management The management of rhinitis depends on the cause, which may be identified in the history and physical examination. The examiner asks the patient about recent symptoms as well as possible exposure to allergens in the home, environment, or workplace. If viral rhinitis is the cause, medications are given to relieve the symptoms. In allergic rhinitis, tests may be performed to identify possible allergens. Depending on the severity of the allergy, desensitizing immunizations and corticosteroids may be required (see Chap. 53 for more details). If symptoms suggest a bacterial infection, an antimicrobial agent will be used (see “Medical Management of Sinusitis”). PHARMACOLOGIC THERAPY Medication therapy for allergic and nonallergic rhinitis focuses on symptom relief. Antihistamines are administered for sneezing, itching, and rhinorrhea. Oral decongestant agents are used for nasal obstruction. In addition, intranasal corticosteroids may be used for severe congestion, and ophthalmic agents are used to relieve irritation, itching, and redness of the eyes.
Nursing Management TEACHING PATIENTS SELF-CARE The nurse instructs the patient with allergic rhinitis to avoid or reduce exposure to allergens and irritants, such as dusts, molds, animals, fumes, odors, powders, sprays, and tobacco smoke. The patient is instructed about the importance of controlling the environment at home and work. Saline nasal or aerosol sprays may be helpful in soothing mucous membranes, softening crusted secretions, and removing irritants. The nurse instructs the patient in the proper use of and technique for administrating nasal medications. To achieve maximal relief, the patient is instructed to blow the nose before applying any medication into the nasal cavity. In the case of infectious rhinitis, the nurse reviews with the patient hand hygiene technique as a measure to prevent transmission of organisms. The nurse teaches methods to treat symptoms of the viral rhinitis. In the elderly and other high-risk populations, the nurse reviews the value of receiving a vaccination
Glossary alaryngeal communication: alternative modes of speaking that do not involve the normal larynx; used by patients whose larynx has been surgically removed aphonia: impaired ability to use one’s voice due to disease or injury to the larynx apnea: cessation of breathing dysphagia: difficulties in swallowing epistaxis: hemorrhage from the nose due to rupture of tiny, distended vessels in the mucous membrane of any area of the nose herpes simplex: cold sore (cutaneous viral infection with painful vesicles and
erosions on the tongue, palate, gingival, buccal membranes, or lips) laryngitis: inflammation of the larynx; may be due to voice abuse, exposure to irritants, or infectious organisms laryngectomy: removal of all or part of the larynx and surrounding structures pharyngitis: inflammation of the throat; usually viral or bacterial in origin rhinitis: inflammation of the mucous membranes of the nose; may be infectious, allergic, or inflammatory in origin
rhinorrhea: drainage of a large amount of fluid from the nose sinusitis: inflammation of the sinuses; may be acute or chronic; may be viral, bacterial, or fungal in origin submucous resection: surgical procedure to correct nasal obstruction due to deviated septum; also called septoplasty tonsillitis: inflammation of the tonsils, usually due to an acute infection xerostomia: dryness of the mouth from a variety of causes
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Physiology/Pathophysiology A. Rhinitis
Edematous conchae; polyps may develop
Occluded sinus openings
of the mucous membranes of the nasal cavity. More broadly, the term refers to an acute upper respiratory tract infection, whereas terms such as “rhinitis,” “pharyngitis,” and “laryngitis” distinguish the sites of the symptoms. It can also be used when the causative virus is influenza (“the flu”). Colds are highly contagious because virus is shed for about 2 days before the symptoms appear and during the first part of the symptomatic phase. It is estimated that adults in the United States average two to four colds each year. The common cold is the most common cause of absenteeism from work and school (Mandell, Bennett, & Dolin, 2000). The six viruses known to produce the signs and symptoms of the viral rhinitis are rhinovirus, parainfluenza virus, coronavirus, respiratory syncytial virus (RSV), influenza virus, and adenovirus. Each virus may have multiple strains. For example, there are over 100 strains of rhinovirus, which accounts for 50% of all colds. The incidence of viral rhinitis follows a specific pattern during the year, depending on the causative agent (Fig. 22-2). Even though viral rhinitis can occur at any time of the year, three waves account for the epidemics in the United States:
• In September, just after the opening of school • In late January • Toward the end of April
Enlarged nasal mucosa Discharging mucus
B. Sinusitis
Immunity after recovery is variable and depends on many factors, including a person’s natural host resistance and the specific virus that caused the cold.
Clinical Manifestations Thick mucus occludes sinus cavity and prevents drainage
Signs and symptoms of viral rhinitis are nasal congestion, runny nose, sneezing, nasal discharge, nasal itchiness, tearing watery eyes, “scratchy” or sore throat, general malaise, low-grade fever, chills,
FIGURE 22-1
Pathophysiologic processes in rhinitis and sinusitis. Although pathophysiologic processes are similar in rhinitis and sinusitis, they affect different structures. In rhinitis (A), the mucous membranes lining the nasal passages become inflamed, congested, and edematous. The swollen nasal conchae block the sinus openings, and mucus is discharged from the nostrils. Sinusitis (B) is also marked by inflammation and congestion, with thickened mucous secretions filling the sinus cavities and occluding the openings.
in the fall in order to achieve immunity prior to the beginning of the “flu season.”
VIRAL RHINITIS (COMMON COLD) The term “common cold” often is used when referring to an upper respiratory tract infection that is self-limited and caused by a virus (viral rhinitis). Nasal congestion, rhinorrhea, sneezing, sore throat, and general malaise characterize it. Specifically, the term “cold” refers to an afebrile, infectious, acute inflammation
FIGURE 22-2 Schematic diagram incidence of viral rhinitis (common cold) in the United States and the frequency of the causative agents. Redrawn from Goldman, L. & Bennett, J. C. (eds.) (2000) Cecil textbook of medicine (21st ed., Vol. 2). Philadelphia: W. B. Saunders, p. 1791.
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and often headache and muscle aches. As the illness progresses, cough usually appears. In some people, viral rhinitis exacerbates the herpes simplex, commonly called a cold sore (Chart 22-1). The symptoms last from 1 to 2 weeks. If there is significant fever or more severe systemic respiratory symptoms, it is no longer viral rhinitis but one of the other acute upper respiratory tract infections. Allergic conditions can also affect the nose, mimicking the symptoms of a cold.
Medical Management There is no specific treatment for the common cold or influenza. Management consists of symptomatic therapy. Some measures include providing adequate fluid intake, encouraging rest, preventing chilling, increasing intake of vitamin C, and using expectorants as needed. Warm salt-water gargles soothe the sore throat and nonsteroidal anti-inflammatory agents (NSAIDs) such as aspirin or ibuprofen relieve the aches, pains, and fever in adults. Antihistamines are used to relieve sneezing, rhinorrhea, and nasal congestion. Topical (nasal) decongestant agents may re-
Chart 22-1
Colds and Cold Sores (Herpes Simplex Virus)
The herpes simplex virus (HSV-1) produces the familiar herpes labialis, commonly called a cold sore or fever blister. In the past, this painful blisterlike lip sore was thought to be caused by a cold or a fever. Even now that scientists recognize the origin of herpes labialis, the condition is still referred to as a cold sore. The herpes virus infection remains latent in cells of the lips or nose and is activated by stress, sunlight, and febrile illnesses from the common cold to streptococcal pneumonia, meningococcal meningitis, and even malaria. The incubation period is 2 to 12 days. The virus is transmitted primarily by direct contact with infected secretions. The virus may also be transmitted from an asymptomatic person. Small vesicles, single or clustered, may erupt on the lips, inside the mouth, including the tongue, soft and hard palate, gums, buccal mucosa, and the pharynx. These soon rupture, forming sore shallow ulcers that increase in number. The gums may bleed and feel painful. The herpes virus may subside spontaneously in 10 to 14 days. If it does not, acyclovir, an antiviral agent, may be administered orally or topically to minimize the symptoms and the duration or length of the flare-up. Analgesics, such as acetaminophen (Tylenol) with codeine or aspirin with codeine, are helpful in relieving pain and discomfort. Topical anesthetics, such as lidocaine (Xylocaine) or dyclonine (Dyclone), and over-the-counter preparations, such as Herpecin-L, may relieve oral pain. Applications of drying lotions or liquids may help to dry the lesions.
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lieve nasal congestion; however, if they are overused they may create a rebound congestion that may be worse than the original symptoms. Some research suggests that zinc lozenges may reduce the duration of cold symptoms if taken within the first 24 hours of onset (Prasad, Fitzgerald, & Bao, 2000). Amantadine (Symmetrel) or rimantadine (Flumadine) may be prescribed prophylactically to decrease the signs and symptoms as well. Antimicrobial agents (antibiotics) should not be used because they do not affect the virus or reduce the incidence of bacterial complications.
Nursing Management TEACHING PATIENTS SELF-CARE Most viruses can be transmitted in several ways: direct contact with infected secretions; inhalation of large particles that land on a mucosal surface from coughing or sneezing; or inhalation of small particles (aerosol) that may be suspended in the air for up to an hour. It is important to teach the patient how to break the chain of infection. Hand washing remains the most effective measure to prevent transmission of organisms. The nurse teaches methods to treat symptoms of the common cold and preventive measures (Chart 22-2).
ACUTE SINUSITIS The sinuses, mucus-lined cavities filled with air that drain normally into the nose, are involved in a high proportion of upper respiratory tract infections. If their openings into the nasal passages are clear, the infections resolve promptly. However, if their drainage is obstructed by a deviated septum or by hypertrophied turbinates, spurs, or nasal polyps or tumors, sinus infection may persist as a smoldering secondary infection or progress to an acute suppurative process (causing purulent discharge). Sinusitis affects over 14% of the population and accounts for billions of dollars in direct health care costs (Tierney, McPhee, & Papadakis, 2001). Some individuals are more prone to sinusitis because of their occupations. For example, continuous exposure to environmental hazards such as paint, sawdust, and chemicals may result in chronic inflammation of the nasal passages.
Pathophysiology Acute sinusitis is an infection of the paranasal sinuses. It frequently develops as a result of an upper respiratory infection, such as an unresolved viral or bacterial infection, or an exacerbation of allergic rhinitis. Nasal congestion, caused by inflammation, edema, and transudation of fluid, leads to obstruction of the sinus cavities (see Fig. 22-1). This provides an excellent medium for bacterial growth. Bacterial organisms account for more than 60% of the cases of acute sinusitis, namely Streptococcus pneumoniae, Haemophilus influenzae, and Moraxella catarrhalis (Murray & Nadel, 2001). Dental infections also have been associated with acute sinusitis.
Clinical Manifestations
With permission from Goodheart, H. P. (1999). Photoguide of common skin disorders: Diagnosis and management. Baltimore: Lippincott Williams & Wilkins.
Symptoms of acute sinusitis may include facial pain or pressure over the affected sinus area, nasal obstruction, fatigue, purulent nasal discharge, fever, headache, ear pain and fullness, dental pain, cough, a decreased sense of smell, sore throat, eyelid edema, or facial congestion or fullness. Acute sinusitis can be difficult to differentiate from an upper respiratory infection or allergic rhinitis.
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Chart 22-2 Home Care Checklist • Preventing and Managing Upper Respiratory Infections At the completion of the home care instruction, the patient or caregiver will be able to: Prevention • Identify strategies to prevent infection and, if infected, to prevent spread of infection to others Perform hand hygiene often Use disposable tissues Avoid crowds during the flu season Avoid individuals with colds or respiratory infections Obtain influenza vaccination, if recommended (especially if elderly or diagnosed with a chronic illness) • Practice good health habits Eat a nutritious diet Get plenty of rest and sleep Avoid or reduce stress when possible Exercise appropriately Avoid smoking or second-hand smoke and excessive intake of alcohol Increase humidity in house, especially during winter Practice adequate oral hygiene • Avoid allergens, if allergies are associated with upper respiratory infections Prevention and Management • Identify strategies to control the environment Adequately humidify (avoid overhumidifying) living quarters Place a dehumidifier in the basement, if appropriate Provide central ventilation fans, air conditioning with microstatic air filters Reduce irritants (dust, chemical, tobacco smoke) when possible Limit exposure to animals and house pets, particularly in the bedroom Management • Describe strategies to relieve symptoms of upper respiratory infection Gargle with salt water Increase fluid intake, particularly of hot liquids Provide warm, moist air by shower or humidifier to relieve swollen mucous membranes Avoid irritants (dust, chemicals, tobacco smoke) when possible • Recognize signs and symptoms of infection and state when to contact a health care provider Upper respiratory infection symptoms persisting longer than 7 to 10 days Extreme red throat or white patches on the back of the throat Discolored drainage or foul-smelling nasal discharge Prolonged fever of 100.5°F (38°C) >2 days Shortness of breath, wheezing Swollen lymph nodes Severe pain or tenderness around the eyes or persistent pain in sinus areas Severe headache
Assessment and Diagnostic Findings A careful history and physical examination are performed. The head and neck, particularly the nose, ears, teeth, sinuses, pharynx, and chest, are examined. There may be tenderness to palpation over the infected sinus area. The sinuses are percussed using the index finger, tapping lightly to determine if the patient experiences pain. The affected area is also transilluminated; with sinusitis, there is a decrease in the transmission of light (see Chap. 21, Fig. 21-8). Sinus x-rays may be performed to detect sinus opacity, mucosal thickening, bone destruction, and air–fluid levels. Computed tomography scanning of the sinuses is the most effective diagnostic tool. It is also used to rule out other local or systemic disorders, such as tumor, fistula, and allergy.
Complications Acute sinusitis, if left untreated, may lead to severe and occasionally life-threatening complications such as meningitis, brain abscess, ischemic infarction, and osteomyelitis. Other complica-
Patient
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tions of sinusitis, although uncommon, include severe orbital cellulitis, subperiosteal abscess, and cavernous sinus thrombosis.
Medical Management The goals of treatment of acute sinusitis are to treat the infection, shrink the nasal mucosa, and relieve pain. There is a growing concern over the inappropriate use of antibiotics for viral upper respiratory infections; such overuse has resulted in antibiotics being less effective (more resistant) in treating bacterial infections such as sinusitis. As a result, careful consideration is given to the potential pathogen before antimicrobial agents are prescribed. The antimicrobial agents of choice for a bacterial infection vary in clinical practice. First-line antibiotics include amoxicillin (Amoxil), trimethoprim/sulfamethoxazole (Bactrim, Septra), and erythromycin. Second-line antibiotics include cephalosporins such as cefuroxime axetil (Ceftin), cefpodoxime (Vantin), and cefprozil (Cefzil) and amoxicillin clavulanate (Augmentin). Newer and more expensive antibiotics with a broader spectrum include
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macrolides, azithromycin (Zithromax), and clarithromycin (Biaxin). Quinolones such as ciprofloxacin (Cipro), levofloxacin (Levaquin) (used with severe penicillin allergy), and sparfloxacin (Zagam) have also been used. The course of treatment is usually 10 to 14 days. A recent report found little difference in clinical outcomes between first-line and second-line antibiotics; however, costs were greater when newer second-line antibiotics were used (Piccirillo, Mager, Frisse et al., 2001). Use of oral and topical decongestant agents may decrease mucosal swelling of nasal polyps, thereby improving drainage of the sinuses. Heated mist and saline irrigation also may be effective for opening blocked passages. Decongestant agents such as pseudoephedrine (Sudafed, Dimetapp) have proven effective because of their vasoconstrictive properties. Topical decongestant agents such as oxymetazoline (Afrin) may be used for up to 72 hours. It is important to administer them with the patient’s head tilted back to promote maximal dispersion of the medication. Guaifenesin (Robitussin, Anti-Tuss), a mucolytic agent, may also be effective in reducing nasal congestion. In 2000, the U.S. Food and Drug Administration issued a public health advisory concerning phenylpropanolamine, which previously had been commonly used in oral decongestants and diet pills. The voluntary recall of products containing this ingredient was based on a study linking its use with hemorrhagic stroke in women. Men may also be at risk (Kernan et al., 2000). Antihistamines such as diphenhydramine (Benadryl), cetirizine (Zyrtec), and fexofenadine (Allegra) may be used if an allergic component is suspected. If the patient continues to have symptoms after 7 to 10 days, the sinuses may need to be irrigated and hospitalization may be required.
Nursing Management TEACHING PATIENTS SELF-CARE Patient teaching is an important aspect of nursing care for the patient with acute sinusitis. The nurse instructs the patient about methods to promote drainage such as inhaling steam (steam bath, hot shower, and facial sauna), increasing fluid intake, and applying local heat (hot wet packs). The nurse also informs the patient about the side effects of nasal sprays and about rebound congestion. In the case of rebound congestion, the body’s receptors, which have become dependent on the decongestant sprays to keep the nasal passages open, close and congestion results after the spray is discontinued. The nurse stresses the importance of following the recommended antibiotic regimen, because a consistent blood level of the medication is critical to treat the infection. The nurse teaches the patient the early signs of a sinus infection and recommends preventive measures such as following healthy practices and avoiding contact with people who have upper respiratory infections (see Chart 22-2). The nurse should explain to the patient that fever, severe headache, and nuchal rigidity are signs of potential complications. If fever persists despite antibiotic therapy, the patient should seek additional care.
CHRONIC SINUSITIS Chronic sinusitis is an inflammation of the sinuses that persists for more than 3 weeks in an adult and 2 weeks in a child. It is estimated that 32 million people a year develop chronic sinusitis.
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Pathophysiology A narrowing or obstruction in the ostia of the frontal, maxillary, and anterior ethmoid sinuses usually causes chronic sinusitis, preventing adequate drainage to the nasal passages. This combined area is known as the osteomeatal complex. Blockage that persists for greater than 3 weeks in an adult may occur because of infection, allergy, or structural abnormalities. This results in stagnant secretions, an ideal medium for infection. The organisms that cause chronic sinusitis are the same as those implicated in acute sinusitis. Immunocompromised patients, however, are at increased risk for developing fungal sinusitis. Aspergillus fumigatus is the most common organism associated with fungal sinusitis.
Clinical Manifestations Clinical manifestations of chronic sinusitis include impaired mucociliary clearance and ventilation, cough (because the thick discharge constantly drips backward into the nasopharynx), chronic hoarseness, chronic headaches in the periorbital area, and facial pain. These symptoms are generally most pronounced on awakening in the morning. Fatigue and nasal stuffiness are also common. In addition, some patients experience a decrease in smell and taste and a fullness in the ears.
Assessment and Diagnostic Findings A careful history and diagnostic assessment, including a computed tomography scan of the sinuses or magnetic resonance imaging (if fungal sinusitis is suspected), are performed to rule out other local or systemic disorders, such as tumor, fistula, and allergy. Nasal endoscopy may be indicated to rule out underlying diseases such as tumors and sinus mycetomas (fungus balls). The fungus ball is usually a brown or greenish-black material with the consistency of peanut butter or cottage cheese.
Complications Complications of chronic sinusitis, although uncommon, include severe orbital cellulitis, subperiosteal abscess, cavernous sinus thrombosis, meningitis, encephalitis, and ischemic infarction.
Medical Management Medical management of chronic sinusitis is almost the same as for acute sinusitis. The antimicrobial agents of choice include amoxicillin clavulanate (Augmentin) or ampicillin (Ampicin). Clarithromycin (Biaxin) and third-generation cephalosporins such as cefuroxime axetil (Ceftin), cefpodoxime (Vantin), and cefprozil (Cefzil) have also been effective. Levofloxacin (Levaquin), a quinolone, may also be used. The course of treatment may be 3 to 4 weeks. Decongestant agents, antihistamines, saline sprays, and heated mist may also provide some symptom relief. SURGICAL MANAGEMENT When standard medical therapy fails, surgery, usually endoscopic, may be indicated to correct structural deformities that obstruct the ostia (openings) of the sinus. Excising and cauterizing nasal polyps, correcting a deviated septum, incising and draining the sinuses, aerating the sinuses, and removing tumors are some of the specific procedures performed. When sinusitis is caused by a fungal infection, surgery is required to excise the fungus ball and necrotic tissue and drain the sinuses. Oral and topical cortico-
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steroids are usually prescribed. Antimicrobial agents are administered before and after surgery. Some patients with severe chronic sinusitis obtain relief only by moving to a dry climate.
Nursing Management Because the patient usually performs care measures for sinusitis at home, nursing management consists mainly of patient teaching. TEACHING PATIENTS SELF-CARE The nurse teaches the patient how to promote sinus drainage by increasing the environmental humidity (steam bath, hot shower, and facial sauna), increasing fluid intake, and applying local heat (hot wet packs). The nurse also instructs the patient about the importance of following the medication regimen. Instructions on the early signs of a sinus infection are provided and preventive measures are reviewed.
ACUTE PHARYNGITIS Acute pharyngitis is an inflammation or infection in the throat, usually causing symptoms of a sore throat.
Pathophysiology Most cases of acute pharyngitis are caused by viral infection. When group A beta-hemolytic streptococcus, the most common bacterial organism, causes acute pharyngitis, the condition is known as strep throat (Bisno, 2001). The body responds by triggering an inflammatory response in the pharynx. This results in pain, fever, vasodilation, edema, and tissue damage, manifested by redness and swelling in the tonsillar pillars, uvula, and soft palate. A creamy exudate may be present in the tonsillar pillars (Fig. 22-3). Uncomplicated viral infections usually subside promptly, within 3 to 10 days after the onset. However, pharyngitis caused by more virulent bacteria such as group A beta-hemolytic streptococci is a more severe illness. If left untreated, the complications can be severe and life-threatening. Complications include sinusitis, otitis media, peritonsillar abscess, mastoiditis, and cervical adenitis. In rare cases the infection may lead to bacteremia, pneumonia, meningitis, rheumatic fever, or nephritis.
Assessment and Diagnostic Findings Rapid screening tests for streptococcal antigens such as the latex agglutination (LA) antigen test and solid-phase enzyme immunoassays (ELISA), optical immunoassay (OIA), streptolysin titers, and throat cultures are used to determine the causative organism, after which appropriate therapy is prescribed. Nasal swabs and blood cultures may also be necessary to identify the organism (Corneli, 2001).
Medical Management Viral pharyngitis is treated with supportive measures since antibiotics will have no effect on the organism. Bacterial pharyngitis is treated with a variety of antimicrobial agents. PHARMACOLOGIC THERAPY If a bacterial cause is suggested or demonstrated, penicillin is usually the treatment of choice. For patients who are allergic to penicillin or have organisms that are resistant to erythromycin (one fifth of group A beta-hemolytic streptococci and most S. aureus organisms are resistant to penicillin and erythromycin), cephalosporins and macrolides (clarithromycin and azithromycin) may be used. Antibiotics are administered for at least 10 days to eradicate the infection from the oropharynx. Severe sore throats can also be relieved by analgesic medications, as prescribed. For example, aspirin or acetaminophen (Tylenol) can be taken at 3- to 6-hour intervals; if required, acetaminophen with codeine can be taken three or four times daily. Antitussive medication, in the form of codeine, dextromethorphan (Robitussin DM), or hydrocodone bitartrate (Hycodan), may be required to control the persistent and painful cough that often accompanies acute pharyngitis. NUTRITIONAL THERAPY A liquid or soft diet is provided during the acute stage of the disease, depending on the patient’s appetite and the degree of discomfort that occurs with swallowing. Occasionally, the throat is so sore that liquids cannot be taken in adequate amounts by mouth. In severe situations, fluids are administered intravenously. Otherwise, the patient is encouraged to drink as much fluid as possible (at least 2 to 3 L per day).
Clinical Manifestations The signs and symptoms of acute pharyngitis include a fiery-red pharyngeal membrane and tonsils, lymphoid follicles that are swollen and flecked with white-purple exudate, and enlarged and tender cervical lymph nodes and no cough. Fever, malaise, and sore throat also may be present.
Nursing Management The nurse instructs the patient to stay in bed during the febrile stage of illness and to rest frequently once up and about. Used tissues should be disposed of properly to prevent the spread of infection. It is important to examine the skin once or twice daily for
FIGURE 22-3
A
B
Pharyngitis—inflammation without exudate. (A) Redness and vascularity of the pillars and uvula are mild to moderate. (B) Redness is diffuse and intense. Each patient would probably complain of a sore throat. From Bickley, L. S. (2003). Bates’ guide to physical examination and history taking (8th ed.). Philadelphia: Lippincott Williams & Wilkins.
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possible rash, because acute pharyngitis may precede some other communicable diseases (ie, rubella). Warm saline gargles or irrigations are used depending on the severity of the lesion and the degree of pain. The benefits of this treatment depend on the degree of heat that is applied. The nurse teaches the patient about the recommended temperature of the solution: high enough to be effective and as warm as the patient can tolerate, usually 105°F to 110°F (40.6°C to 43.3°C). Irrigating the throat properly is an effective means of reducing spasm in the pharyngeal muscles and relieving soreness of the throat. Unless the purpose of the procedure and its technique are understood clearly by the patient and family, the results may be less than satisfactory. An ice collar also can relieve severe sore throats. Mouth care may add greatly to the patient’s comfort and prevent the development of fissures (cracking) of the lips and oral inflammation when bacterial infection is present. The nurse instructs the patient to resume activity gradually. A full course of antibiotic therapy is indicated in patients with group A beta-hemolytic streptococcal infection in view of the possible development of complications such as nephritis and rheumatic fever, which may have their onset 2 or 3 weeks after the pharyngitis has subsided. The nurse instructs the patient and family about the importance of taking the full course of therapy and informs them about the symptoms to watch for that may indicate complications.
Nursing Management
CHRONIC PHARYNGITIS
Clinical Manifestations
Chronic pharyngitis is a persistent inflammation of the pharynx. It is common in adults who work or live in dusty surroundings, use their voice to excess, suffer from chronic cough, and habitually use alcohol and tobacco. Three types of chronic pharyngitis are recognized:
The symptoms of tonsillitis include sore throat, fever, snoring, and difficulty swallowing. Enlarged adenoids may cause mouthbreathing, earache, draining ears, frequent head colds, bronchitis, foul-smelling breath, voice impairment, and noisy respiration. Unusually enlarged adenoids fill the space behind the posterior nares, making it difficult for the air to travel from the nose to the throat and resulting in a nasal obstruction. Infection can extend to the middle ears by way of the auditory (eustachian) tubes and may result in acute otitis media, which can lead to spontaneous rupture of the eardrums and further extension of the infection into the mastoid cells, causing acute mastoiditis. The infection also may reside in the middle ear as a chronic, low-grade, smoldering process that eventually may cause permanent deafness.
• Hypertrophic: characterized by general thickening and congestion of the pharyngeal mucous membrane
• Atrophic: probably a late stage of the first type (the mem•
brane is thin, whitish, glistening, and at times wrinkled) Chronic granular (“clergyman’s sore throat”): characterized by numerous swollen lymph follicles on the pharyngeal wall
TEACHING PATIENTS SELF-CARE To prevent the infection from spreading, the nurse instructs the patient to avoid contact with others until the fever subsides. Alcohol, tobacco, second-hand smoke, and exposure to cold are avoided, as are environmental or occupational pollutants if possible. The patient may minimize exposure to pollutants by wearing a disposable facemask. The nurse encourages the patient to drink plenty of fluids. Gargling with warm saline solutions may relieve throat discomfort. Lozenges will keep the throat moistened.
TONSILLITIS AND ADENOIDITIS The tonsils are composed of lymphatic tissue and are situated on each side of the oropharynx. The faucial or palatine tonsils and lingual tonsils are located behind the pillars of fauces and tongue, respectively. They frequently serve as the site of acute infection (tonsillitis). Chronic tonsillitis is less common and may be mistaken for other disorders such as allergy, asthma, and sinusitis. The adenoids or pharyngeal tonsils consist of lymphatic tissue near the center of the posterior wall of the nasopharynx. Infection of the adenoids frequently accompanies acute tonsillitis. Group A beta-streptococcus is the most common organism associated with tonsillitis and adenoiditis.
Clinical Manifestations
Assessment and Diagnostic Findings
Patients with chronic pharyngitis complain of a constant sense of irritation or fullness in the throat, mucus that collects in the throat and can be expelled by coughing, and difficulty swallowing.
A thorough physical examination is performed and a careful history is obtained to rule out related or systemic conditions. The tonsillar site is cultured to determine the presence of bacterial infection. In adenoiditis, if recurrent episodes of suppurative otitis media result in hearing loss, the patient should be given a comprehensive audiometric examination (see Chap. 59).
Medical Management Treatment of chronic pharyngitis is based on relieving symptoms, avoiding exposure to irritants, and correcting any upper respiratory, pulmonary, or cardiac condition that might be responsible for a chronic cough. Nasal congestion may be relieved by short-term use of nasal sprays or medications containing ephedrine sulfate (Kondon’s Nasal) or phenylephrine hydrochloride (Neo-Synephrine). If there is a history of allergy, one of the antihistamine decongestant medications, such as Drixoral or Dimetapp, is taken orally every 4 to 6 hours. Aspirin or acetaminophen is recommended for its antiinflammatory and analgesic properties.
Medical Management Tonsillectomy is usually performed for recurrent tonsillitis when medical treatment is unsuccessful and there is severe hypertrophy, asymmetry, or peritonsillar abscess that occludes the pharynx, making swallowing difficult and endangering the airway (particularly during sleep). Enlargement of the tonsils is rarely an indication for their removal; most children normally have large tonsils, which decrease in size with age. Despite the continuing debate over the effectiveness of many tonsillectomies, the operation is still a common surgical procedure in the United States.
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Tonsillectomy or adenoidectomy is indicated only if the patient has had any of the following problems: repeated bouts of tonsillitis; hypertrophy of the tonsils and adenoids that could cause obstruction and obstructive sleep apnea; repeated attacks of purulent otitis media; suspected hearing loss due to serous otitis media that has occurred in association with enlarged tonsils and adenoids; and some other conditions, such as an exacerbation of asthma or rheumatic fever. Appropriate antibiotic therapy is initiated for patients undergoing tonsillectomy or adenoidectomy. The most common antimicrobial agent is oral penicillin, which is taken for 7 days. Amoxicillin and erythromycin are alternatives.
Nursing Management PROVIDING POSTOPERATIVE CARE Continuous nursing observation is required in the immediate postoperative and recovery period because of the significant risk of hemorrhage. In the immediate postoperative period, the most comfortable position is prone with the head turned to the side to allow drainage from the mouth and pharynx. The nurse must not remove the oral airway until the patient’s gag and swallowing reflexes have returned. The nurse applies an ice collar to the neck, and a basin and tissues are provided for the expectoration of blood and mucus. Bleeding may be bright red if the patient expectorates blood before swallowing it Often, however, the patient swallows the blood, which immediately becomes brown because of the action of the acidic gastric juice. Hemorrhage is a potential complication after a tonsillectomy and adenoidectomy. If the patient vomits large amounts of dark blood or bright-red blood at frequent intervals, or if the pulse rate and temperature rise and the patient is restless, the nurse notifies the surgeon immediately. The nurse should have the following items ready for examination of the surgical site for bleeding: a light, a mirror, gauze, curved hemostats, and a waste basin. Occasionally, suture or ligation of the bleeding vessel is required. In such cases, the patient is taken to the operating room and given general anesthesia. After ligation, continuous nursing observation and postoperative care are required, as in the initial postoperative period. If there is no bleeding, water and ice chips may be given to the patient as soon as desired. The patient is instructed to refrain from too much talking and coughing because these activities can produce throat pain. TEACHING PATIENTS SELF-CARE Tonsillectomy and adenoidectomy usually do not require hospitalization and are performed as outpatient surgery with a short length of stay. Because the patient will be sent home soon after surgery, the patient and family must understand the signs and symptoms of hemorrhage. Hemorrhage usually occurs in the first 12 to 24 hours. The patient is instructed to report frank red bleeding to the physician. Alkaline mouthwashes and warm saline solutions are useful in coping with the thick mucus and halitosis that may be present after surgery. It is important to explain to the patient that a sore throat, stiff neck, and vomiting may occur in the first 24 hours. A liquid or semiliquid diet is given for several days. Sherbet and gelatin are acceptable foods. The patient should avoid spicy, hot, acidic, or rough foods. Milk and milk products (ice cream and yogurt) may be restricted because they may make removal of mucus more difficult.
The nurse explains to the patient that halitosis and some minor ear pain may occur for the first few days. The nurse instructs the patient to avoid vigorous tooth brushing or gargling, since these actions could cause bleeding.
PERITONSILLAR ABSCESS A peritonsillar abscess is a collection of purulent exudate between the tonsillar capsule and the surrounding tissues, including the soft palate. It is believed to develop after an acute tonsillar infection, which progresses to a local cellulitis and abscess.
Clinical Manifestations The usual symptoms of an infection are present, together with such local symptoms as a raspy voice, odynophagia (a severe sensation of burning, squeezing pain while swallowing), dysphagia (difficulty swallowing), otalgia (pain in the ear), and drooling. An examination shows marked swelling of the soft palate, often occluding almost half of the opening from the mouth into the pharynx, unilateral tonsillar hypertrophy, and dehydration.
Assessment and Diagnostic Findings Aspiration of purulent material (pus) by needle aspiration is required to make the appropriate diagnosis. The aspirated material is sent for culture and Gram’s stain. A CTscan is performed when it is not possible to aspirate the abscess.
Medical Management Antibiotics (usually penicillin) are extremely effective in controlling the infection in peritonsillar abscess. If antibiotics are prescribed early in the course of the disease, the abscess may resolve without needing to be incised. SURGICAL MANAGEMENT If treatment is delayed, the abscess is evacuated as soon as possible. The mucous membrane over the swelling is first sprayed with a topical anesthetic and then injected with a local anesthetic. Single or repeated needle aspirations are performed to decompress the abscess. The abscess may also be incised and drained. These procedures are performed best with the patient in the sitting position to make it easier to expectorate the pus and blood that accumulate in the pharynx. Almost immediate relief is experienced. Approximately 30% of patients with peritonsillar abscess have indications for tonsillectomy (Tierney et al., 2001).
Nursing Management Considerable relief may be obtained by the use of topical anesthetic agents and throat irrigations or the frequent use of mouthwashes or gargles, using saline or alkaline solutions at a temperature of 105°F to 110°F (40.6°C to 43.3°C). The nurse instructs the patient to gargle at intervals of 1 or 2 hours for 24 to 36 hours. Liquids that are cool or at room temperature are usually well tolerated.
LARYNGITIS Laryngitis, an inflammation of the larynx, often occurs as a result of voice abuse or exposure to dust, chemicals, smoke, and other pollutants, or as part of an upper respiratory tract infection.
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It also may be caused by isolated infection involving only the vocal cords. The cause of infection is almost always a virus. Bacterial invasion may be secondary. Laryngitis is usually associated with allergic rhinitis or pharyngitis. The onset of infection may be associated with exposure to sudden temperature changes, dietary deficiencies, malnutrition, and an immunosuppressed state. Laryngitis is common in the winter and is easily transmitted.
ings such as redness, asymmetry, or evidence of drainage, ulceration, or enlargement. Next the nurse palpates the trachea to determine the midline position in the neck and to detect any masses or deformities. The neck lymph nodes also are palpated for associated enlargement and tenderness.
Clinical Manifestations
NURSING DIAGNOSES Based on the assessment data, the patient’s major nursing diagnoses may include the following:
Signs of acute laryngitis include hoarseness or aphonia (complete loss of voice) and severe cough. Chronic laryngitis is marked by persistent hoarseness. Laryngitis may be a complication of upper respiratory infections.
Medical Management Management of acute laryngitis includes resting the voice, avoiding smoking, resting, and inhaling cool steam or an aerosol. If the laryngitis is part of a more extensive respiratory infection due to a bacterial organism or if it is severe, appropriate antibacterial therapy is instituted. The majority of patients recover with conservative treatment; however, laryngitis tends to be more severe in elderly patients and may be complicated by pneumonia. For chronic laryngitis, the treatment includes resting the voice, eliminating any primary respiratory tract infection, eliminating smoking, and avoiding second-hand smoke. Topical corticosteroids, such as beclomethasone dipropionate (Vanceril) inhalation, may also be used. These preparations have no systemic or long-lasting effects and may reduce local inflammatory reactions.
Nursing Management The nurse instructs the patient to rest the voice and to maintain a well-humidified environment. If laryngeal secretions are present during acute episodes, expectorant agents are suggested, along with a daily fluid intake of 3 L to thin secretions.
NURSING PROCESS: THE PATIENT WITH UPPER AIRWAY INFECTION Assessment A health history may reveal signs and symptoms of headache, sore throat, pain around the eyes and on either side of the nose, difficulty in swallowing, cough, hoarseness, fever, stuffiness, and generalized discomfort and fatigue. Determining when the symptoms began, what precipitated them, what if anything relieves them, and what aggravates them is part of the assessment. It also is important to determine any history of allergy or the existence of a concomitant illness. Inspection may reveal swelling, lesions, or asymmetry of the nose as well as bleeding or discharge. The nurse inspects the nasal mucosa for abnormal findings such as increased redness, swelling, or exudate, and nasal polyps, which may develop in chronic rhinitis. The nurse palpates the frontal and maxillary sinuses for tenderness, which suggests inflammation, and then inspects the throat by having the patient open the mouth wide and take a deep breath. The tonsils and pharynx are inspected for abnormal find-
Diagnosis
• Ineffective airway clearance related to excessive mucus pro-
duction secondary to retained secretions and inflammation
• Acute pain related to upper airway irritation secondary to an infection
• Impaired verbal communication related to physiologic • •
changes and upper airway irritation secondary to infection or swelling Deficient fluid volume related to increased fluid loss secondary to diaphoresis associated with a fever Deficient knowledge regarding prevention of upper respiratory infections, treatment regimen, surgical procedure, or postoperative care
COLLABORATIVE PROBLEMS/ POTENTIAL COMPLICATIONS Based on assessment data, potential complications may include:
• • • • •
Sepsis Meningitis Peritonsillar abscess Otitis media Sinusitis
Planning and Goals The major goals for the patient may include maintenance of a patent airway, relief of pain, maintenance of effective means of communication, normal hydration, knowledge of how to prevent upper airway infections, and absence of complications.
Nursing Interventions MAINTAINING A PATENT AIRWAY An accumulation of secretions can block the airway in patients with an upper airway infection. As a result, changes in the respiratory pattern occur, and the work of breathing required to get beyond the blockage increases. The nurse can implement several measures to loosen thick secretions or to keep the secretions moist so that they can be easily expectorated. Increasing fluid intake helps thin the mucus. Use of room vaporizers or steam inhalation also loosens secretions and reduces inflammation of the mucous membranes. To enhance drainage from the sinuses, the nurse instructs the patient about the best position to assume; this depends on the location of the infection or inflammation. For example, drainage for sinusitis or rhinitis is achieved in the upright position. In some conditions, topical or systemic medications, when prescribed, help to relieve nasal or throat congestion. PROMOTING COMFORT Upper respiratory tract infections usually produce localized discomfort. In sinusitis, pain may occur in the area of the sinuses or
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may produce a general headache. In pharyngitis, laryngitis, or tonsillitis, a sore throat occurs. The nurse encourages the patient to take analgesics, such as acetaminophen with codeine, as prescribed, which will help relieve this discomfort. Other helpful measures include topical anesthetic agents for symptomatic relief of herpes simplex blisters (see Chart 22-1) and sore throats, hot packs to relieve the congestion of sinusitis and promote drainage, and warm water gargles or irrigations to relieve the pain of a sore throat. The nurse encourages rest to relieve the generalized discomfort and fever that accompany many upper airway conditions (especially rhinitis, pharyngitis, and laryngitis). The nurse instructs the patient in general hygiene techniques to prevent the spread of infection. For postoperative care following tonsillectomy and adenoidectomy, an ice collar may reduce swelling and decrease bleeding. PROMOTING COMMUNICATION Upper airway infections may result in hoarseness or loss of speech. The nurse instructs the patient to refrain from speaking as much as possible and to communicate in writing instead, if possible. Additional strain on the vocal cords may delay full return of the voice. ENCOURAGING FLUID INTAKE In upper airway infections, the work of breathing and the respiratory rate increase as inflammation and secretions develop. This, in turn, may increase insensible fluid loss. Fever further increases the metabolic rate, diaphoresis, and fluid loss. Sore throat, malaise, and fever may interfere with a patient’s willingness to eat. The nurse encourages the patient to drink 2 to 3 L of fluid per day during the acute stage of airway infection, unless contraindicated, to thin secretions and promote drainage. Liquids (hot or cold) may be soothing, depending on the illness. PROMOTING HOME AND COMMUNITY-BASED CARE Teaching Patients Self-Care Prevention of most upper airway infections is difficult because of the many potential causes. However, most upper respiratory infections are transmitted by hand-to-hand contact. Therefore, it is important to teach the patient and family how to minimize the spread of infection to others. Other preventive strategies are identified in Chart 22-2. The nurse advises the patient to avoid exposure to others at risk for serious illness if respiratory infection is transmitted. Those at risk include elderly adults, immunosuppressed people, and those with chronic health problems. The nurse teaches patients and their families strategies to relieve symptoms of upper respiratory infections. These include increasing the humidity level, encouraging adequate fluid intake, getting adequate rest, using warm water gargles or irrigations and topical anesthetic agents to relieve sore throat, and applying hot packs to relieve congestion. The nurse reinforces the need to complete the treatment regimen, particularly when antibiotics are prescribed. Continuing Care Referral for home care is rare. However, it may be indicated for the person whose health status was compromised before the onset of the respiratory infection and for those who cannot manage selfcare without assistance. In such circumstances, the home care nurse assesses the patient’s respiratory status and progress in recovery. The nurse may advise elderly patients and those who would be at increased risk from a respiratory infection to consider
an annual influenza vaccine. A follow-up appointment with the primary care provider may be indicated for patients with compromised health status to ensure that the respiratory infection has resolved. MONITORING AND MANAGING POTENTIAL COMPLICATIONS While major complications of upper respiratory infections are rare, the nurse must be aware of them and assess the patient for them. Because most patients with upper respiratory infections are managed at home, patients and their families must be instructed to monitor for signs and symptoms and to seek immediate medical care if the patient’s condition does not improve or if the patient’s physical status appears to be worsening. Sepsis and meningitis may occur in patients with compromised immune status or in those with an overwhelming bacterial infection. The patient with an upper respiratory infection and family members are instructed to seek medical care if the patient’s condition fails to improve within several days of the onset of symptoms, if unusual symptoms develop, or if the patient’s condition deteriorates. They are instructed about signs and symptoms that require further attention: persistent or high fever, increasing shortness of breath, confusion, and increasing weakness and malaise. The patient with sepsis requires expert care to treat the infection, stabilize vital signs, and prevent or treat septicemia and shock. Deterioration of the patient’s condition necessitates intensive care measures (eg, hemodynamic monitoring and administration of vasoactive medications, intravenous fluids, nutritional support, corticosteroids) to monitor the patient’s status and to support the patient’s vital signs. High doses of antibiotics may be administered to treat the causative organism. The nurse’s role is to monitor the patient’s vital signs, hemodynamic status, and laboratory values, administer needed treatment, alleviate the patient’s physical discomfort, and provide explanations, teaching, and emotional support to the patient and family. Peritonsillar abscess may develop following an acute infection of the tonsils. The patient requires treatment to drain the abscess and receives antibiotics for infection and topical anesthetic agents and throat irrigations to relieve pain and sore throat. Follow-up is necessary to ensure that the abscess resolves; tonsillectomy may be required. The nurse assists the patient in administering throat irrigations and instructs the patient and family about the importance of adhering to the prescribed treatment regimen and recommended follow-up appointments. Otitis media and sinusitis may develop with upper respiratory infection. The patient and family are instructed about the signs and symptoms of otitis media and sinusitis and about the importance of follow-up with the primary health care practitioner to ensure adequate evaluation and treatment of these conditions.
Evaluation EXPECTED PATIENT OUTCOMES Expected patient outcomes may include: 1. Maintains a patent airway by managing secretions a. Reports decreased congestion b. Assumes best position to facilitate drainage of secretions 2. Reports feeling more comfortable a. Uses comfort measures: analgesics, hot packs, gargles, rest b. Demonstrates adequate oral hygiene 3. Demonstrates ability to communicate needs, wants, level of comfort
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4. Maintains adequate fluid intake 5. Identifies strategies to prevent upper airway infections and allergic reactions a. Demonstrates hand hygiene technique b. Identifies the value of the influenza vaccine 6. Demonstrates an adequate level of knowledge and performs self-care adequately 7. Becomes free of signs and symptoms of infection a. Exhibits normal vital signs (temperature, pulse, respiratory rate) b. Absence of purulent drainage c. Free of pain in ears, sinuses, and throat
Obstruction and Trauma of the Upper Respiratory Airway
Chart 22-3
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• ASSESSMENT
Obstructive Sleep Apnea Clinical features of obstructive sleep apnea include: Excessive daytime sleepiness Frequent nocturnal awakening Insomnia Loud snoring Morning headaches Intellectual deterioration Personality changes, irritability Impotence Systemic hypertension Dysrhythmias Pulmonary hypertension, cor pulmonale Polycythemia Enuresis
OBSTRUCTION DURING SLEEP A variety of respiratory disorders are associated with sleep, the most common being sleep apnea syndrome. Sleep apnea syndrome is defined as cessation of breathing (apnea) during sleep.
Pathophysiology Sleep apnea is classified into three types:
• Obstructive—lack of air flow due to pharyngeal occlusion • Central—simultaneous cessation of both air flow and respiratory movements
• Mixed—a combination of central and obstructive apnea within one apneic episode
The most common type of sleep apnea syndrome, obstructive sleep apnea, will be presented here.
Clinical Manifestations It is estimated that 12 million Americans have sleep apnea (National Institute of Health, 2000). It is more prevalent in men, especially those who are older and overweight. Cigarette smoking is a risk factor. Obstructive sleep apnea is defined as frequent and loud snoring and breathing cessation for 10 seconds or more for five episodes per hour or more, followed by awakening abruptly with a loud snort as the blood oxygen level drops. Patients with sleep apnea may experience anywhere from five apneic episodes per hour to several hundred per night. Other symptoms include excessive daytime sleepiness, morning headache, sore throat, intellectual deterioration, personality changes, behavioral disorders, enuresis, impotence, obesity, and complaints by the partner that the patient snores loudly or is unusually restless during sleep (Chart 22-3). The obstruction may be caused by mechanical factors such as a reduced diameter of the upper airway or dynamic changes in the upper airway during sleep. The activity of the tonic dilator muscles of the upper airway is reduced during sleep. These sleeprelated changes may predispose the patient to increased upper airway collapse with the small amounts of negative pressure generated during inspiration. Obstructive sleep apnea may be associated with obesity and with other conditions that reduce pharyngeal muscle tone (eg, neuromuscular disease, sedative/ hypnotic medications, acute ingestion of alcohol). The diagnosis of sleep apnea is made based on clinical features plus polysomnographic findings (sleep test), in which the cardiopulmonary status of the patient is monitored during an episode of sleep.
The effects of obstructive sleep apnea can seriously tax the heart and lungs. Repetitive apneic events result in hypoxia and hypercapnia, which triggers a sympathetic response. As a consequence, patients have a high prevalence of hypertension and an increased risk of myocardial infarction and stroke. In patients with underlying cardiovascular disease, the nocturnal hypoxemia may predispose to dysrhythmias.
Medical Management Patients usually seek medical treatment because their partners express concern or because they experience excessive sleeplessness at inappropriate times or settings (eg, while driving a car). A variety of treatments are used. In mild cases, the patient is advised to avoid alcohol and medications that depress the upper airway and to lose weight. In more severe cases involving hypoxemia with severe CO2 retention (hypercapnia), the treatment includes continuous positive airway pressure or bilevel positive airway pressure therapy with supplemental oxygen via nasal cannula. These treatment methods are described in Chapter 25. Surgical procedures (eg, uvulopalatopharyngoplasty) may be performed to correct the obstruction. As a last resort, a tracheostomy is performed to bypass the obstruction if the potential for respiratory failure or life-threatening dysrhythmias exists. The tracheostomy is unplugged only during sleep. Although this is an effective treatment, it is used in a limited number of patients because of its associated physical disfigurement (Murray & Nadel, 2001). PHARMACOLOGIC THERAPY Treatment of central sleep apnea also includes medication. Protriptyline (Triptil) given at bedtime is thought to increase the respiratory drive and improve upper airway muscle tone. Medroxyprogesterone acetate (Provera) and acetazolamide (Diamox) have been recommended for sleep apnea associated with chronic alveolar hypoventilation, but their benefits have not been well established. Administration of low-flow nasal oxygen at night can help relieve hypoxemia in some patients but has little effect on the frequency or severity of apnea.
Nursing Management The patient with obstructive sleep apnea may not recognize the potential consequences of the disorder. Therefore, the nurse explains the disorder in language that is understandable to the
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patient and relates symptoms (daytime sleepiness) to the underlying disorder. The nurse also instructs the patient and family about treatments, including the correct and safe use of oxygen, if prescribed.
EPISTAXIS (NOSEBLEED) A hemorrhage from the nose, referred to as epistaxis, is caused by the rupture of tiny, distended vessels in the mucous membrane of any area of the nose. Rarely does epistaxis originate in the densely vascular tissue over the turbinates. Most commonly, the site is the anterior septum, where three major blood vessels enter the nasal cavity: (1) the anterior ethmoidal artery on the forward part of the roof (Kesselbach’s plexus), (2) the sphenopalatine artery in the posterosuperior region, and (3) the internal maxillary branches (the plexus of veins located at the back of the lateral wall under the inferior turbinate). There are a variety of causes associated with epistaxis, including trauma, infection, inhalation of illicit drugs, cardiovascular diseases, blood dyscrasias, nasal tumors, low humidity, a foreign body in the nose, and a deviated nasal septum. Additionally, vigorous nose blowing and nose picking have been associated with epistaxis.
Nursing Management
Medical Management Management of epistaxis depends on the location of the bleeding site. A nasal speculum or headlight may be used to determine the site of bleeding in the nasal cavity. Most nosebleeds originate from the anterior portion of the nose. Initial treatment may include applying direct pressure. The patient sits upright with the head tilted forward to prevent swallowing and aspiration of blood and is directed to pinch the soft outer portion of the nose against the midline septum for 5 or 10 minutes continuously. If this measure is unsuccessful, additional treatment is indicated. In anterior nosebleeds, the area may be treated with a silver nitrate applicator and Gelfoam, or by electrocautery. Topical vasoconstrictors,
A
C
such as adrenaline (1⬊1,000), cocaine (0.5%), and phenylephrine may be prescribed. If bleeding is occurring from the posterior regions, cotton pledgets soaked in a vasoconstricting solution may be inserted into the nose to reduce the blood flow and improve the examiner’s view of the bleeding site. Alternatively, a cotton tampon may be used to try to stop the bleeding. Suction may be used to remove excess blood and clots from the field of inspection. The search for the bleeding site should shift from the anteroinferior quadrant to the anterosuperior, then to the posterosuperior, and finally to the posteroinferior area. The field is kept clear by using suction and by shifting the cotton tampon. Only about 60% of the total nasal cavity can actually be seen, however. When the origin of the bleeding cannot be identified, the nose may be packed with gauze impregnated with petrolatum jelly or antibiotic ointment; a topical anesthetic spray and decongestant agent may be used prior to inserting the gauze packing, or a balloon-inflated catheter may be used (Fig. 22-4). The packing may remain in place for 48 hours or up to 5 or 6 days if necessary to control bleeding. Antibiotics may be prescribed because of the risk of iatrogenic sinusitis and toxic shock syndrome.
The nurse monitors the vital signs, assists in the control of bleeding, and provides tissues and an emesis basin to allow the patient to expectorate any excess blood. It is not uncommon for patients to be anxious in response to a nosebleed. Blood loss on clothing and handkerchiefs can be frightening, and the nasal examination and treatment are uncomfortable. Assuring the patient in a calm, efficient manner that bleeding can be controlled can help reduce anxiety. TEACHING PATIENTS SELF-CARE Discharge teaching includes reviewing ways to prevent epistaxis: avoiding forceful nose blowing, straining, high altitudes, and
B
D
FIGURE 22-4 Packing to control bleeding from the posterior nose. (A) Catheter is inserted and packing is attached. (B) Packing is drawn into position as the catheter is removed. (C) Strip is tied over a bolster to hold the packing in place with an anterior pack installed “accordion pleat” style. (D) Alternative method, using a balloon catheter instead of gauze packing.
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nasal trauma (including nose picking). Adequate humidification may prevent drying of the nasal passages. The nurse instructs the patient how to apply direct pressure to the nose with the thumb and the index finger for 15 minutes in the case of a recurrent nosebleed. If recurrent bleeding cannot be stopped, the patient is instructed to seek additional medical attention.
NASAL OBSTRUCTION The passage of air through the nostrils is frequently obstructed by a deviation of the nasal septum, hypertrophy of the turbinate bones, or the pressure of nasal polyps, which are grapelike swellings that arise from the mucous membrane of the sinuses, especially the ethmoids. This obstruction also may lead to a condition of chronic infection of the nose and result in frequent episodes of nasopharyngitis. Frequently, the infection extends to the sinuses of the nose. When sinusitis develops and the drainage from these cavities is obstructed by deformity or swelling within the nose, pain is experienced in the region of the affected sinus.
Medical Management The treatment of nasal obstruction requires the removal of the obstruction, followed by measures to overcome whatever chronic infection exists. In many patients an underlying allergy requires treatment. At times endoscopic surgery is necessary to drain the nasal sinuses. The specific procedure performed depends on the type of nasal obstruction found. Usually, surgery is performed under local anesthesia. If a deviation of the septum is the cause of the obstruction, the surgeon makes an incision into the mucous membrane and, after raising it from the bone, removes the deviated bone and cartilage with bone forceps. The mucosa then is allowed to fall back in place and is held there by tight packing. Generally, the packing is soaked in liquid petrolatum so that it can be removed easily in 24 to 36 hours. This operation is called a submucous resection or septoplasty. Nasal polyps are removed by clipping them at their base with a wire snare. Hypertrophied turbinates may be treated by applying an astringent agent to shrink them.
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Assessment and Diagnostic Findings The nose is examined internally to rule out the possibility that the injury may be complicated by a fracture of the nasal septum and a submucosal septal hematoma. Because of the swelling and bleeding that occur with a nasal fracture, an accurate diagnosis can be made only after the swelling subsides. Clear fluid draining from either nostril suggests a fracture of the cribriform plate with leakage of cerebrospinal fluid. Because cerebrospinal fluid contains glucose, it can readily be differentiated from nasal mucus by means of a dipstick (Dextrostix). Usually, careful inspection or palpation will disclose any deviations of the bone or disruptions of the nasal cartilages. An x-ray may reveal displacement of the fractured bones and may help rule out extension of the fracture into the skull.
Medical Management As a rule, bleeding is controlled with the use of cold compresses. The nose is assessed for symmetry either before swelling has occurred or after it has subsided. The patient is referred to a specialist, usually 3 to 5 days after the injury, to evaluate the need to realign the bones. Nasal fractures are surgically reduced 7 to 10 days after the injury.
Nursing Management The nurse instructs the patient to apply ice packs to the nose for 20 minutes four times each day to decrease swelling. The patient who experiences bleeding from the nose (epistaxis) because of injury or for unexplained reasons is usually frightened and anxious. The packing inserted to stop the bleeding may be uncomfortable and unpleasant, and obstruction of the nasal passages by the packing forces the patient to breathe through the mouth. This in turn causes the oral mucous membranes to become dry. Mouth rinses will help to moisten the mucous membranes and to reduce the odor and taste of dried blood in the oropharynx and nasopharynx.
LARYNGEAL OBSTRUCTION
The location of the nose makes it susceptible to injury by a wide variety of causes. In fact, nasal fractures are more common than those of any other bone in the body. Fractures of the nose usually result from a direct assault. As a rule, no serious consequences result, but the deformity that may follow often gives rise to obstruction of the nasal air passages and to facial disfigurement.
Edema of the larynx is a serious, often fatal, condition. The larynx is a stiff box that will not stretch. It contains a narrow space between the vocal cords (glottis) through which air must pass. Swelling of the laryngeal mucous membranes, therefore, may close off the opening tightly, leading to suffocation. Edema of the glottis occurs rarely in patients with acute laryngitis, occasionally in patients with urticaria, and more frequently in patients with severe inflammations of the throat, as in scarlet fever. It is an occasional cause of death in severe anaphylaxis (angioneurotic edema). Foreign bodies frequently are aspirated into the pharynx, the larynx, or the trachea and cause a twofold problem. First, they obstruct the air passages and cause difficulty in breathing, which may lead to asphyxia; later, they may be drawn farther down, entering the bronchi or a bronchial branch and causing symptoms of irritation, such as a croupy cough, expectoration of blood or mucus, or labored breathing. The physical signs and x-ray findings confirm the diagnosis.
Clinical Manifestations
Medical Management
The signs and symptoms of a nasal fracture are bleeding from the nose externally and internally into the pharynx, swelling of the soft tissues adjacent to the nose, and deformity.
When the obstruction is caused by edema resulting from an allergic reaction, treatment includes administering subcutaneous epinephrine or a corticosteroid (see Chap. 53) and applying an
Nursing Management Most of these procedures are performed on an outpatient basis. If the patient is hospitalized, the nurse elevates the head of the bed to promote drainage and to help alleviate discomfort from edema. Frequent oral hygiene is encouraged to overcome dryness caused by breathing through the mouth.
FRACTURES OF THE NOSE
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ice pack to the neck. In emergencies caused by obstruction by a foreign body, when signs of asphyxia are apparent, immediate treatment is necessary. Frequently, if the foreign body has lodged in the pharynx and can be visualized, the finger can dislodge it. If the obstruction is in the larynx or the trachea, the nurse or other rescuer tries the subdiaphragmatic abdominal thrust maneuver (Chart 22-4). If all efforts are unsuccessful, an immediate tracheotomy is necessary (see Chap. 25 for further discussion).
Cancer of the Larynx Cancer of the larynx is a malignant tumor in the larynx (voice box). It is potentially curable if detected early. It represents less than 1% of all cancers and occurs about four times more frequently in men than in women, and most commonly in persons 50 to 70 years of age. The incidence of laryngeal cancer continues to decline, but the incidence in women versus men continues to increase. Each year in the United States, approximately 9,000 new cases are discovered, and 3,700 persons with cancer of the larynx will die (American Cancer Society, 2002). Carcinogens that have been associated with the development of laryngeal cancer include tobacco (smoke, smokeless) and alcohol and their combined effects, exposure to asbestos, mustard gas, wood dust, cement dust, tar products, leather, and metals. Other contributing factors include straining the voice, chronic laryngitis, nutritional deficiencies (riboflavin), and family predisposition (Chart 22-5). A malignant growth may occur in three different areas of the larynx: the glottic area (vocal cords), supraglottic area (area above the glottis or vocal cords, including epiglottis and false cords), and subglottis (area below the glottis or vocal cords to the cricoid). Two thirds of laryngeal cancers are in the glottic area. Supraglottic cancers account for approximately one third of the cases, subglottic tumors for less than 1%. Glottic tumors seldom spread if found early because of the limited lymph vessels found in the vocal cords (Lenhard, Osteen, & Gansler, 2001).
Chart 22-4
Performing the Abdominal Thrust Maneuver
To assist a patient or other person who is choking on a foreign object, the nurse performs the abdominal thrust maneuver (sometimes called the Heimlich maneuver) according to guidelines set forth by the American Heart Association. (Note: Hands crossed at the neck is the universal sign for choking.) 1. Stand behind the person who is choking. 2. Place both arms around the person’s waist. 3. Make a fist with one hand with the thumb outside the fist. 4. Place thumb side of fist against the person’s abdomen above the navel and below the xiphoid process. 5. Grasp fist with other hand. 6. Quickly and forcefully exert pressure against the person’s diaphragm, pressing upward with quick, firm thrusts. 7. Apply thrusts 6 to 10 times until the obstruction is cleared. 8. The pressure from the thrusts should lift the diaphragm, force air into the lungs, and create an artificial cough powerful enough to expel the aspirated object.
Chart 22-5
Risk Factors for Laryngeal Cancer Carcinogens Tobacco (smoke, smokeless) Combined effects of alcohol and tobacco Asbestos Second-hand smoke Paint fumes Wood dust Cement dust Chemicals Tar products Mustard gas Leather and metals Other Factors Straining the voice Chronic laryngitis Nutritional deficiencies (riboflavin) History of alcohol abuse Familial predisposition Age (higher incidence after 60 years of age) Gender (more common in men) Race (more prevalent in African Americans) Weakened immune system
Clinical Manifestations Hoarseness of more than 2 weeks’ duration is noted early in the patient with cancer in the glottic area because the tumor impedes the action of the vocal cords during speech. The voice may sound harsh, raspy, and lower in pitch. Affected voice sounds are not early signs of subglottic or supraglottic cancer. The patient may complain of a cough or sore throat that does not go away and pain and burning in the throat, especially when consuming hot liquids or citrus juices. A lump may be felt in the neck. Later symptoms include dysphagia, dyspnea (difficulty breathing), unilateral nasal
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obstruction or discharge, persistent hoarseness, persistent ulceration, and foul breath. Cervical lymph adenopathy, unplanned weight loss, a general debilitated state, and pain radiating to the ear may occur with metastasis.
Assessment and Diagnostic Findings An initial assessment includes a complete history and physical examination of the head and neck. This will include assessment of risk factors, family history, and any underlying medical conditions. An indirect laryngoscopy, using a flexible endoscope, is initially performed in the otolaryngologist’s office to visually evaluate the pharynx, larynx, and possible tumor. Mobility of the vocal cords is assessed; if normal movement is limited, the growth may affect muscle, other tissue, and even the airway. The lymph
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nodes of the neck and the thyroid gland are palpated to determine spread of the malignancy (Haskell, 2001). If a tumor of the larynx is suspected on an initial examination, a direct laryngoscopic examination is scheduled. This examination is done under local or general anesthesia and allows evaluation of all areas of the larynx. Samples of the suspicious tissue are obtained for histologic evaluation. The tumor may involve any of the three areas of the larynx and may vary in appearance. Squamous cell carcinoma accounts for over 90% of the cases of laryngeal carcinoma (Haskell, 2001). The staging of the tumor serves as a framework for the therapeutic regimen. The TNM classification system, developed by the American Joint Committee on Cancer (AJCC) (Chart 22-6), is the accepted method used to classify head and neck tumors. The classification of the tumor determines the suggested treatment modalities. Because many of
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these lesions are submucosal, biopsy may require that an incision be made using microlaryngeal techniques or using a CO2 laser to transect the mucosa and reach the tumor. Computed tomography and magnetic resonance imaging (MRI) are used to assess regional adenopathy and soft tissue and to help stage and determine the extent of a tumor. MRI is also helpful in post-treatment follow-up in order to detect a recurrence. Positron emission tomography (PET scan) may also be used to detect recurrence of a laryngeal tumor after treatment.
Medical Management Treatment of laryngeal cancer depends on the staging of the tumor, which includes the location, size, and histology of the tumor and the presence and extent of cervical lymph node involvement. Treatment options include surgery, radiation therapy, and chemotherapy. The prognosis depends on a variety of factors: tumor stage, the patient’s gender and age, and pathologic features of the tumor, including the grade and depth of infiltration. The treatment plan also depends on whether this is an initial diagnosis or a recurrence. Small glottic tumors, stage I and II, with no infiltration to the lymph nodes are associated with a 75% to 95% survival rate. Patients with stage III and IV or advanced tumors have a 50% to 60% survival rate and have a 50% chance of recurrence and a 30% chance of metastasis. The highest risk of laryngeal cancer recurrence is in the first 2 to 3 years. Recurrence after 5 years is rare and is usually due to a new primary malignancy (Lenhard et al., 2001) (Chart 22-7). Surgery and radiation therapy are both effective methods in the early stages of cancer of the larynx. Chemotherapy traditionally has been used for recurrence or metastatic disease. It has also been used more recently in conjunction with either radiation
Chart 22-7
• Ethics and Related Issues
Situation A 68-year-old attorney was diagnosed with cancer of the larynx 8 years ago. He was treated successfully with radiation therapy, resulting in an altered voice quality. Recently, he has complained of shortness of breath and difficulty swallowing. In the past few months, he also has noticed a marked change in his voice and physical condition, which he attributed to “winter colds.” After a complete physical exam and an extensive diagnostic workup and biopsy, it is determined that the cancer has recurred at a new primary site. His health care provider recommends surgery (a total laryngectomy) and chemotherapy as the best options. The patient states that he is not willing to “lose my voice and my livelihood” but instead will “take my chances.” He has also expressed concern about his quality of life after surgery. His family has approached you about trying to convince him to have surgery. Dilemma The patient’s right to refuse treatment conflicts with the family’s wishes and recommendation from his health care provider. Discussion 1. Is the patient making a decision based upon all pertinent information concerning his health status, treatment, options, risk/benefits, and long-term prognosis? 2. What arguments can be made to support the patient’s decision to forego treatment? 3. What arguments can be made to question the patient’s decision to forego treatment?
therapy to avoid a total laryngectomy or preoperatively to shrink a tumor before surgery. A complete dental examination is performed to rule out any oral disease. Any dental problems are resolved, if possible, prior to surgery. If surgery is to be performed, a multidisciplinary team evaluates the needs of the patient and family to develop a successful plan of care (Forastiere et al., 2001). SURGICAL MANAGEMENT Recent advances in surgical techniques for treating laryngeal cancer may minimize the ensuing cosmetic and functional deficits. Depending on the location and staging of the tumor, four different types of laryngectomy (surgical removal of part or all of the larynx and surrounding structures) are considered:
• • • •
Partial laryngectomy Supraglottic laryngectomy Hemilaryngectomy Total laryngectomy
Some microlaryngeal surgery can be performed endoscopically. The CO2 laser can be used for the treatment of many laryngeal tumors, with the exception of large vascular tumors. Partial Laryngectomy. A partial laryngectomy (laryngofissure– thyrotomy) is recommended in the early stages of cancer in the glottic area when only one vocal cord is involved. The surgery is associated with a very high cure rate. It may also be performed for a recurrence when high-dose radiation has failed. A portion of the larynx is removed, along with one vocal cord and the tumor; all other structures remain. The airway remains intact and the patient is expected to have no difficulty swallowing. The voice quality may change or the patient may be hoarse. Supraglottic Laryngectomy. A supraglottic laryngectomy is indicated in the management of early (stage I) supraglottic and stage II lesions. The hyoid bone, glottis, and false cords are removed. The true vocal cords, cricoid cartilage, and trachea remain intact. During surgery, a radical neck dissection is performed on the involved side. A tracheostomy tube (see Chap. 25) is left in the trachea until the glottic airway is established. It is usually removed after a few days and the stoma is allowed to close. Nutrition is provided through a nasogastric tube until there is healing, followed by a semisolid diet. Postoperatively, the patient may experience some difficulty swallowing for the first 2 weeks. Aspiration is a potential complication since the patient must learn a new method of swallowing (supraglottic swallowing). The chief advantage of this surgical procedure is that it preserves the voice, even though the quality of the voice may change. Speech therapy is required before and after surgery. The major problem is the high risk for recurrence of the cancer; therefore, patients are selected carefully. Hemilaryngectomy. A hemilaryngectomy is performed when the tumor extends beyond the vocal cord but is less than 1 cm in size and is limited to the subglottic area. It may be used in stage I glottic lesions. In this procedure, the thyroid cartilage of the larynx is split in the midline of the neck and the portion of the vocal cord (one true cord and one false cord) is removed with the tumor. The arytenoid cartilage and half of the thyroid are removed. The patient will have a tracheostomy tube and nasogastric tube in place for 10 to 14 days following surgery. The patient is at risk for aspiration postoperatively. Some change may occur in the voice quality. The voice may be rough, raspy, and hoarse and have limited projection. The airway and swallowing remain intact.
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Total Laryngectomy. A total laryngectomy is performed in the most advanced stage IV laryngeal cancer, when the tumor extends beyond the vocal cords, or for recurrent or persistent cancer following radiation therapy. In a total laryngectomy, the laryngeal structures are removed, including the hyoid bone, epiglottis, cricoid cartilage, and two or three rings of the trachea. The tongue, pharyngeal walls, and trachea are preserved. A total laryngectomy will result in permanent loss of the voice and a change in the airway. Many surgeons recommend that a radical neck dissection be performed on the same side as the lesion even if no lymph nodes are palpable because metastasis to the cervical lymph nodes is common. Surgery is more difficult when the lesion involves the midline structures or both vocal cords. With or without neck dissection, a total laryngectomy requires a permanent tracheal stoma because the larynx that provides the protective sphincter is no longer present. The tracheal stoma prevents the aspiration of food and fluid into the lower respiratory tract. The patient will have no voice but will have normal swallowing. A total laryngectomy changes the manner in which airflow is used for breathing and speaking, as depicted in Figure 22-5. Complications that may occur include a salivary leak, wound infection from the development of a pharyngocutaneous fistula, stomal stenosis, and dysphagia secondary to pharyngeal and cervical esophageal stricture.
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Nasal cavity Soft palate Speech
Pharynx Epiglottis Larynx Vocal cords Trachea
Lung
Diaphragm
A
RADIATION THERAPY The goal of radiation therapy is to eradicate the cancer and preserve the function of the larynx. The decision to use radiation therapy is based on several factors, including the staging of the tumor (usually used for stage I and stage II tumors as a standard treatment option) and the patient’s overall health status, lifestyle (including occupation), and personal preference. Excellent results have been achieved with radiation therapy in patients with earlystage (I and II) glottic tumors when only one vocal cord is involved and there is normal mobility (ie, moves with phonation) and in small supraglottic lesions. One of the benefits of radiation therapy is that patients retain a near-normal voice. A few may develop chondritis (inflammation of the cartilage) or stenosis; a small number may later require laryngectomy. Radiation therapy may also be used preoperatively to reduce the tumor size. Radiation therapy is combined with surgery in advanced (stages III and IV) laryngeal cancer as adjunctive therapy to surgery or chemotherapy, and as a palliative measure. A variety of clinical trials have combined chemotherapy and radiation therapy in the treatment of advanced laryngeal tumors. Early studies suggest that combined modality therapy may improve the tumor’s response to radiation therapy. Radiation therapy combined with chemotherapy may be an alternative to a total laryngectomy. The complications from radiation therapy are a result of external radiation to the head and neck area, which may also include the parotid gland responsible for mucus production. The symptoms may include acute mucositis, ulceration of the mucous membranes, pain, xerostomia (dry mouth), loss of taste, dysphasia, fatigue, and skin reactions. Later complications may include laryngeal necrosis, edema, and fibrosis.
writing, lip speaking, and communication or word boards. A system of communication is established with the patient, family, nurse, and physician and implemented consistently after surgery. A postoperative communication plan is also developed. The three most common techniques of alaryngeal communication are esophageal speech, artificial larynx (electrolarynx), and tracheoesophageal puncture. Training in these techniques begins once medical clearance is obtained from the physician.
SPEECH THERAPY The loss or alteration of speech is discussed with the patient and family before surgery, and the speech therapist conducts a preoperative evaluation. During this time, the nurse should inform the patient and family about methods of communication that will be available in the immediate postoperative period. These include
Esophageal Speech. Esophageal speech was the primary method of alaryngeal speech taught to patients until the 1980s. The patient needs the ability to compress air into the esophagus and expel it, setting off a vibration of the pharyngeal esophageal segment. The technique can be taught once the patient begins oral feedings, approximately 1 week after surgery. First, the patient
Minimal air entering nose and mouth Surgical tie-off
Air flowing to lungs in and out of opening in neck
B
FIGURE 22-5 Total laryngectomy produces a change in airflow for breathing and speaking. (A) Normal airflow. (B) Airflow after total laryngectomy.
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learns to belch and is reminded to do so an hour after eating. Then the technique is practiced repeatedly. Later, this conscious belching action is transformed into simple explosions of air from the esophagus for speech purposes. Thereafter, the speech therapist works with the patient in an attempt to make speech intelligible and as close to normal as possible. Because it takes a long time to become proficient, the success rate is low. Electric Larynx. If esophageal speech is not successful, or until the patient masters the technique, an electric larynx may be used for communication. This battery-powered apparatus projects sound into the oral cavity. When the mouth forms words (articulated), the sounds from the electric larynx become audible words. The voice that is produced sounds mechanical, and some words may be difficult to distinguish. The advantage is that the patient is able to communicate with relative ease while working to become proficient at either esophageal or tracheoesophageal puncture speech. Tracheoesophageal Puncture. The third technique of alaryngeal speech is tracheoesophageal puncture (Fig. 22-6). This technique is the most widely used because the speech associated with it most resembles normal speech (the sound produced is a combination of esophageal speech and voice), and it is easily learned. A valve is placed in the tracheal stoma to divert air into the esophagus and out of the mouth. Once the puncture is surgically created and has healed, a voice prosthesis (Blom–Singer) is fitted over the puncture site. To prevent airway obstruction, the prosthesis is removed and cleaned when mucus builds up. A speech therapist teaches the patient how to produce sounds. Moving the tongue and lips to form the sound into words produces speech as before. Tracheoesophageal speech is successful in 80% to 90% of patients (DeLisa & Gans, 1998).
NURSING PROCESS: THE PATIENT UNDERGOING LARYNGECTOMY Assessment The nurse assesses the patient for the following symptoms: hoarseness, sore throat, dyspnea, dysphagia, or pain and burning in the throat. The neck is palpated for swelling. If treatment includes surgery, the nurse must know the nature of the surgery to plan appropriate care. If the patient is expected to have no voice, a preoperative evaluation by the speech therapist is indicated. The patient’s ability to hear, see, read, and write is assessed. Visual impairment and functional illiteracy may create additional problems with communication and require creative approaches to ensure that the patient is able to communicate any needs. In addition, the nurse determines the psychological readiness of the patient and family. The idea of cancer is terrifying to most people. Fear is compounded by the possibility of permanently losing one’s voice and, in some cases, of having some degree of disfigurement. The nurse evaluates the patient’s and family’s coping methods to support them effectively both preoperatively and postoperatively.
Diagnosis NURSING DIAGNOSES Based on all the assessment data, major nursing diagnoses may include the following:
• Deficient knowledge about the surgical procedure and postoperative course
• Anxiety and depression related to the diagnosis of cancer and impending surgery
• Ineffective airway clearance related to excess mucus production secondary to surgical alterations in the airway
• Impaired verbal communication related to anatomic deficit
secondary to removal of the larynx and to edema
• Imbalanced nutrition: less than body requirements, related to inability to ingest food secondary to swallowing difficulties
• Disturbed body image and low self-esteem secondary to •
Voice prosthesis Tracheostoma valve
major neck surgery, change in the structure and function of the larynx Self-care deficit related to pain, weakness, fatigue, musculoskeletal impairment related to surgical procedure and postoperative course
COLLABORATIVE PROBLEMS/ POTENTIAL COMPLICATIONS Based on assessment data, potential complications that may develop include:
• Respiratory distress (hypoxia, airway obstruction, tracheal edema)
• Hemorrhage • Infection • Wound breakdown FIGURE 22-6
Schematic representation of tracheoesophageal puncture speech (TEP). Air travels from the lung through a puncture in the posterior wall of the trachea into the esophagus and out the mouth. A voice prosthesis is fitted over the puncture site.
Planning and Goals The major goals for the patient may include attainment of an adequate level of knowledge, reduction in anxiety, maintenance of a patent airway (patient is able to handle own secretions), effec-
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tive use of alternative means of communication, attainment of optimal levels of nutrition and hydration, improvement in body image and self-esteem, improved self-care management, and absence of complications.
Nursing Interventions TEACHING THE PATIENT PREOPERATIVELY The diagnosis of laryngeal cancer is associated with misconceptions and fears. Many people assume that loss of speech and disfigurement are inevitable with this condition. Once the physician explains the diagnosis to the patient, the nurse clarifies any misconceptions by identifying the location of the larynx, its function, the nature of the surgical procedure, and its effect on speech. Informational materials (written and audiovisual) about the surgery are given to the patient and family for review and reinforcement. If a complete laryngectomy is planned, the patient should know that the natural voice will be lost, but that special training can provide a means for communicating. However, the ability to sing, laugh, or whistle will be lost. Until this training is initiated, the patient needs to know that communication will be possible by using the call light or special communication board and by writing. The nurse answers questions about the nature of the surgery and reinforces the physician’s explanation that the patient will lose the ability to vocalize, but that a rehabilitation program is available. The multidisciplinary team conducts an initial assessment of the patient and family. The team might include the nurse, physician, respiratory therapist, speech therapist, clinical nurse specialist, social worker, dietitian, and home care nurse. Next, the nurse reviews equipment and treatments for postoperative care with the patient and family, teaches important coughing and deep-breathing exercises, and assists the patient to perform a return demonstration. The nurse clarifies the patient’s role in the postoperative and rehabilitation periods. REDUCING ANXIETY AND DEPRESSION Because surgery of the larynx is performed most commonly for a malignant tumor, the patient may have many questions: Will the surgeon be able to remove all of the tumor? Is it cancer? Will I die? Will I choke? Will I suffocate? Will I ever speak again? What will I look like? The psychological preparation of the patient is as important as the physical preparation. Any patient undergoing surgery may have many fears. In laryngeal surgery, these fears may relate to the diagnosis of cancer and may be compounded by the possibility of permanent loss of the voice and disfigurement. The nurse provides the patient and family with opportunities to ask questions, verbalize feelings, and discuss perceptions. It is important to address any questions and misconceptions the patient and family have. During the preoperative or postoperative period, a visit from someone who has had a laryngectomy may reassure the patient that people are available to help and that rehabilitation is possible. MAINTAINING A PATENT AIRWAY The nurse promotes a patent airway by positioning the patient in the semi-Fowler’s or Fowler’s position after recovery from anesthesia. Observing the patient for restlessness, labored breathing, apprehension, and increased pulse rate helps the nurse identify possible respiratory or circulatory problems. Medications that depress respiration, particularly opioids, should be used cautiously. As with other surgical patients, the nurse encourages the laryngectomy patient to turn, cough, and take deep breaths. If necessary, suctioning may be performed to remove secretions. The
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nurse also encourages and assists the patient with early ambulation to prevent atelectasis and pneumonia. If a total laryngectomy was performed, a laryngectomy tube will most likely be in place. (In some instances a laryngectomy tube is not used; in others it is used temporarily, and in many it is used permanently.) The laryngectomy tube, which is shorter than a tracheostomy tube but has a larger diameter, is the patient’s only airway. The care of this tube is the same as for a tracheostomy tube (see Chap. 25). The nurse cleans the stoma daily with saline solution or another prescribed solution. If a non–oilbased antibiotic ointment is prescribed, the nurse applies it around the stoma and suture line. If crusting appears around the stoma, the nurse removes the crusts with sterile tweezers and applies additional ointment. Wound drains may be in place to assist in removal of fluid and air from the surgical site. Suction also may be used, but cautiously, to avoid trauma to the surgical site and incision. The nurse observes, measures, and records drainage. When drainage is less than 50 to 60 mL/day, the physician usually removes the drains. Frequently, the patient coughs up large amounts of mucus through this opening. Because air passes directly into the trachea without being warmed and moistened by the upper respiratory mucosa, the tracheobronchial tree compensates by secreting excessive amounts of mucus. Therefore, the patient will have frequent coughing episodes and may develop a brassy-sounding, mucus-producing cough. The nurse should reassure the patient that these problems will diminish in time as the tracheobronchial mucosa adapts to the altered physiology. After the patient coughs, the tracheostomy opening must be wiped clean and clear of mucus. A simple gauze dressing, washcloth, or even paper towel (because of its size and absorbency) worn below the tracheostomy may serve as a barrier to protect the clothing from the copious mucus that the patient may expel initially. One of the most important factors in decreasing cough, mucus production, and crusting around the stoma is adequate humidification of the environment. Mechanical humidifiers and aerosol generators (nebulizers) increase the humidity and are important for the patient’s comfort. The laryngectomy tube may be removed when the stoma is well healed, within 3 to 6 weeks after surgery. The nurse can teach the patient how to clean and change the tube (see Chap. 25) and remove secretions. PROMOTING ALTERNATIVE COMMUNICATION METHODS Understanding the patient’s postoperative needs is critical. Alternative means of communication are established and used consistently by all personnel who come in contact with the patient—for example, a call bell or hand bell may be placed within easy reach of the patient. Because a Magic Slate often is used for communication, the nurse should document which hand the patient uses for writing so that the opposite arm can be used for intravenous infusions. (The nurse should discard any old notes used for communication to ensure the patient’s privacy.) If the patient cannot write, a picture-word-phrase board or hand signals can be used. Preoperatively, the nurse reviews the system of communication to be used postoperatively with the patient. Because it is very time-consuming to have to write everything or communicate through gestures, the inability to speak can be very frustrating. The patient may become impatient and angry when not understood. In such cases, other staff members need to be alert to the problem and also recognize that the patient will be unable to use the intercom system.
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The return of communication is generally the ultimate goal in the rehabilitation of the laryngectomy patient. The nurse works with the patient, speech therapist, and family to encourage use of alternative communication methods. PROMOTING ADEQUATE NUTRITION Postoperatively, the patient may not be permitted to eat or drink for 10 to 14 days. Alternative sources of nutrition and hydration include intravenous fluids, enteral feedings through a nasogastric tube, and parenteral nutrition. Once the patient is ready to start oral feedings, the nurse explains that thick liquids will be used first because they are easy to swallow. The nurse instructs the patient to avoid sweet foods, which increase salivation and suppress the appetite. Solid foods are introduced as tolerated. The nurse instructs the patient to rinse the mouth with warm water or mouthwash and to brush the teeth frequently. The patient can expect to have a diminished sense of taste and smell for a period of time after surgery. Inhaled air passes directly into the trachea, bypassing the nose and the olfactory end organs. Because taste and smell are so closely connected, taste sensations are altered. In time, however, the patient usually accommodates to this problem and olfactory sensation adapts, often with return of interest in eating. The nurse observes the patient for any difficulty swallowing, particularly when eating resumes, and reports its occurrence to the physician. PROMOTING POSITIVE BODY IMAGE AND SELF-ESTEEM Disfiguring surgery and an altered communication pattern are a threat to a patient’s body image and self-esteem. The reaction of family members and friends is a major concern for the patient. The nurse encourages the patient to express any feelings about the changes brought about by surgery, particularly those related to fear, anger, depression, and isolation. A positive approach is important when caring for the patient. Promoting self-care activities is part of this approach. It is important for the patient and family to begin participating in selfcare activities as soon as possible. The nurse needs to be a good listener and a support to the family, especially when explaining the tubes, dressings, and drains that are in place postoperatively. Referral to a support group, such as Lost Chord or New Voice clubs (through the International Association of Laryngectomees) and I Can Cope (through the American Cancer Society), may help the patient and family deal with the changes in their lives. Groups such as Lost Chord and New Voice promote and support the rehabilitation of people who have had a laryngectomy by providing an opportunity for exchanging ideas and sharing information. MONITORING AND MANAGING POTENTIAL COMPLICATIONS The immediate potential complications after laryngectomy include respiratory distress and hypoxia, hemorrhage, infection, and wound breakdown. Respiratory Distress and Hypoxia The nurse monitors the patient for signs and symptoms of respiratory distress and hypoxia, particularly restlessness, irritation, agitation, confusion, tachypnea, use of accessory muscles, and decreased oxygen saturation on pulse oximetry (SpO2). Any change in the respiratory status requires immediate intervention. Obstruction needs to be ruled out immediately by suctioning and having the patient cough and breathe deeply. Hypoxia and airway obstruction, if not immediately treated, are life-threatening.
The nurse contacts the physician immediately if nursing measures do not improve the patient’s respiratory status. Hemorrhage Bleeding at the surgical site from the drains or with tracheal suctioning may signal the occurrence of hemorrhage. The nurse should notify the surgeon of any active bleeding immediately. Bleeding may occur at a variety of sites, including the surgical site, drains, or trachea. Rupture of the carotid artery is especially dangerous. Should this occur, the nurse should apply direct pressure over the artery, summon assistance, and provide emotional support to the patient until the vessel can be ligated. It is important to monitor vital signs for changes, particularly increased pulse rate, decreased blood pressure, and rapid deep respirations. Cold, clammy, pale skin may indicate active bleeding. Infection The nurse observes for postoperative infection. Early signs of infection include an increase in temperature and pulse, a change in the type of wound drainage, or increased areas of redness or tenderness at the surgical site. Other signs include purulent drainage, odor, and increased wound drainage. The nurse reports any significant change to the surgeon. Wound Breakdown Wound breakdown due to infection, poor wound healing, or development of a fistula or as a result of radiation therapy or tumor growth can create a life-threatening emergency. The carotid artery, which is close to the stoma, may rupture from erosion if the wound does not heal properly. The nurse observes the stoma area for wound breakdown, hematoma, and bleeding and reports any significant changes to the surgeon. If wound breakdown occurs, the patient must be monitored carefully and identified as being at high risk for carotid hemorrhage. PROMOTING HOME AND COMMUNITY-BASED CARE Teaching Patients Self-Care The nurse has an important role in the recovery and rehabilitation of the laryngectomy patient. In an effort to facilitate the patient’s ability to manage self-care, discharge instruction begins as soon as the patient is able to participate. Nursing care and patient teaching in the hospital, outpatient setting, and rehabilitation or long-term care facility must take into consideration the many emotions, physical changes, and lifestyle changes experienced by the patient. In preparing the patient to go home, the nurse assesses the patient’s readiness to learn and the level of knowledge about self-care management. The nurse also reassures the patient and family that most self-care management strategies can be mastered. The patient will need to learn a variety of self-care behaviors, including tracheostomy and stoma care, wound care, and oral hygiene. In addition, the nurse instructs the patient about the need for safe hygiene and recreational activities. Tracheostomy and Stoma Care. The nurse provides specific instructions to the patient and family about what to expect from the tracheostomy and its management. The nurse teaches the patient and family caregiver to perform suctioning and emergency measures and tracheostomy and stoma care. The nurse stresses the importance of humidification at home and instructs the family to set up a humidification system before the patient returns home. In addition, the nurse cautions the patient and family that air-conditioned air may be too cool or too dry, and thus too irritating, for the patient with a new laryngectomy. (See Chap. 25 for details about tracheostomy care.)
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Hygiene and Safety Measures. The nurse instructs the patient and family about safety precautions needed because of the structural changes resulting from the surgery. Special precautions are needed in the shower to prevent water from entering the stoma. Wearing a loose-fitting plastic bib over the tracheostomy or simply holding the hand over the opening is effective. Swimming is not recommended, however, because people with a laryngectomy can drown without getting their face wet. Barbers and beauticians need to be alerted so that hair sprays, loose hair, and powder do not get near the stoma, because they can block or irritate the trachea and possibly cause infection. These self-care points are summarized in Chart 22-8. Recreation and exercise are important, and all but very strenuous exercise can be enjoyed safely. Avoidance of strenuous exercise and fatigue is important because, when tired, the patient has more difficulty speaking, which can be discouraging. Additional safety points to address include the need for the patient to wear or carry medical identification, such as a bracelet or card, to alert medical personnel to the special requirements for resuscitation should this need arise. When resuscitation is needed, direct mouth-to-stoma ventilation should be performed. For home emergency situations, prerecorded emergency messages for police, the fire department, or other rescue services can be kept near the phone to be used quickly. The nurse instructs and encourages the patient to perform oral care on a regular basis to prevent halitosis and infection. If the patient is receiving radiation therapy, there will be a decrease in saliva, and synthetic saliva may be required. The nurse instructs the patient to drink water or sugar-free liquids throughout the day and to use a humidifier at home. Brushing the teeth or dentures and rinsing the mouth several times a day will assist in maintaining proper oral hygiene.
Continuing Care Referral for home care is an important aspect of postoperative care for the patient who has had a laryngectomy and will assist the patient and family in the transition to the home. The home care nurse assesses the patient’s general health status and the ability of the patient and family to care for the stoma and tracheostomy.
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The nurse assesses the surgical incisions, nutritional and respiratory status, and adequacy of pain management. The nurse assesses not only for signs and symptoms of complications but also for the patient’s and family’s knowledge of which signs and symptoms to report to the physician. During the home visit, the nurse identifies and addresses other learning needs of the patient and family, such as adaptation to physical, lifestyle, and functional changes. It is important to assess the patient’s psychological status as well. The home care nurse reinforces previous teaching and provides reassurance and support to the patient and family as needed. The nurse encourages the person who has had a laryngectomy to have regular physical examinations and to seek advice concerning any problems related to recovery and rehabilitation. The patient is also reminded to participate in health promotion activities and health screening and about the importance of keeping scheduled appointments with the physician, speech therapist, and other health care providers.
Evaluation EXPECTED PATIENT OUTCOMES Expected patient outcomes may include: 1. Acquires an adequate level of knowledge, verbalizing an understanding of the surgical procedure and performing self-care adequately 2. Demonstrates less anxiety and depression a. Expresses a sense of hope b. Is aware of available community organizations and agencies such as the Lost Chord or New Voice groups c. Participates in support group, such as I Can Cope 3. Maintains a clear airway and handles own secretions; also demonstrates practical, safe, and correct technique for cleaning and changing the laryngectomy tube 4. Acquires effective communication techniques a. Uses assistive devices and strategies for communication (Magic Slate, call bell, picture board, sign language, lip reading, computer aids) b. Follows the recommendations of the speech therapist
Chart 22-8 Home Care Checklist • The Patient With a Laryngectomy At the completion of the home care instruction, the patient or caregiver will be able to: • Demonstrate methods to clear the airway and handle secretions • Explain the rationale for maintaining adequate humidification with a humidifier or nebulizer • Demonstrate how to clean the skin around the stoma and how to use ointments and tweezers to remove encrustations • State the rationale for wearing a loose-fitting protective cloth at the stoma • Discuss the need to avoid cold air from air conditioning and the environment to prevent irritation of the airway • Demonstrate safe technique in changing the laryngectomy tube • Identify the signs and symptoms of wound infection and state what to do about them • Describe safety or emergency measures to implement in case of breathing difficulty or bleeding • State the rationale for wearing or carrying special medical identification and ways to obtain help in an emergency • Explain the importance of covering the stoma when showering or bathing • Identify fluid and caloric needs • Describe mouth care and discuss its importance • Demonstrate alternative communication methods • Identify support groups and agency resources • State the need for regular check-ups and reporting of any problems immediately
Patient
Caregiver
✓ ✓
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5. Maintains balanced nutrition and adequate fluid intake 6. Exhibits improved body image, self-esteem, and self-concept a. Expresses feelings and concerns b. Participates in self-care and decision making c. Accepts information about support group 7. Exhibits no complications a. Vital signs (blood pressure, temperature, pulse, respiratory rate) normal b. No redness, tenderness, or purulent drainage at surgical site c. Demonstrates a patent airway and appropriate respirations d. No bleeding from surgical site and minimal bleeding from drains e. No wound breakdown 8. Adheres to rehabilitation and home care program a. Practices recommended speech therapy b. Demonstrates proper methods for caring for stoma and laryngectomy tube (if present) c. Verbalizes understanding of symptoms that require medical attention d. States safety measures to take in emergencies e. Performs oral hygiene as prescribed
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Critical Thinking Exercises
1.
A 36-year-old teacher is diagnosed with acute sinusitis. She has been self-medicating with over-the-counter medications for the past 2 weeks with no relief. What assessment and treatment should the nurse anticipate? What teaching and management strategies would you discuss with the patient? What is the rationale for your approach?
2.
Your 68-year-old patient is scheduled for total laryngectomy for treatment of laryngeal cancer. What information would you provide to the patient about managing changes in breathing and speech that are expected in the immediate postoperative period and in the long term? What information would you provide to the patient’s family?
3.
You are making the first home visit to a patient who has just been discharged from the hospital following treatment for pneumonia and a 60-lb weight loss. He had a laryngectomy 8 months ago to treat laryngeal cancer. What will be the focus of your initial home visit? What aspects of assessment and nursing management are key at this point in caring for this patient? How would you assist this patient and his family to plan his care for the next month? Next 6 months?
4.
Your patient, age 36, has been admitted to the emergency department with profuse epistaxis following a car crash. He tells you that he has hemophilia and is HIV-positive as a result of repeated use of clotting factors. What are the initial measures you would use to stop the bleeding? What other options are available if the bleeding does not stop within a reasonable period? How will his HIV status and the diagnosis of hemophilia affect your plan of care for him?
REFERENCES AND SELECTED READINGS Books American Cancer Society. (2002). Cancer facts and figures. Atlanta: American Cancer Society Inc. Bast, R. C., Kufe, D. W., Pollock, R. E., et al. (Eds.) (2000). Holland & Frei cancer medicine (5th ed.) Hamilton: B.C. Decker, Inc. DeLisa, J. A., & Gans, B. M. (1998). Rehabilitation medicine principles and practice (3d ed.). Philadelphia: Lippincott-Raven. Goldman, L., & Bennett, J. C. (Eds.) (2000). Cecil textbook of medicine (21st ed.). Philadelphia: W. B. Saunders. Green, E., et al. (Eds.) (2002). AJCC cancer staging manual (6th ed.). New York: Springer-Verlag. Haskell, C. M. (2001) Cancer treatment (5th ed.). Philadelphia: W. B. Saunders. Lenhard, R. E., Osteen, R. T., & Gansler, T. (2001) The American Cancer Society’s clinical oncology (1st ed.). Atlanta: American Cancer Society Inc. Mandell, G. L., Bennett, J. E., & Dolin, R (Eds.) (2000). Principles and practice of infectious diseases (5th ed.). Philadelphia: Churchill Livingstone. McKenry, L. M., & Salerno, E. (2001). Mosby’s principles in nursing (21st ed.). St. Louis: Mosby. Middleton, E., Ellis, E. F., Yunginger, J. W., et al. (1998). Allergy: principles and practice (Vol. II, 5th ed.). St. Louis: Mosby. Murray, J. F., & Nadel, J. A. (2001). Textbook of respiratory medicine (Vols. 1 & 2, 3d ed.). Philadelphia: W. B. Saunders. Peckenpaugh, N. J., & Poleman, C. M. (1999). Nutrition essentials and diet therapy (8th ed.). Philadelphia: W. B. Saunders. Tierney, L. M., McPhee, S. J., & Papadakis, M. A. (2001). Current medical diagnosis and treatment 2001 (40th ed.). New York: Lange Medical Books/McGraw Hill. Tintinalli, J. E., Kelen, G. D., & Stapczynski, J. S. (2000). Emergency medicine: A comprehensive study guide (5th ed.). New York: McGraw-Hill. Townsend, C. M. (Ed.) (2001). Sabiston textbook of surgery (16th ed.). Philadelphia: W. B. Saunders. Yarbro, C. H., Goodman, M., Frogge, M. H., & Groenwald, S. L. I. (Eds.) (2000). Cancer nursing: Principles and practice (5th ed.). Boston: Jones & Bartlett.
Journals Asterisks indicate nursing research articles. General Casale, T. B., Condemi, J., LaForce, C., et al. (2001). Effect of omalizumab on symptoms of seasonal allergic rhinitis: A randomized controlled trial. Journal of the American Medical Association, 286(23), 2956–2967. Chan, E., & Welsh, C. H. (1998). Geriatric respiratory medicine. Chest, 114(6), 1704–1733. Upper Respiratory Infections Bisno, A. L. (2001) Primary care: Acute pharyngitis. New England Journal of Medicine, 344(3), 205–211. Cifu, A., & Levinson, W. (2000) Influenza. Journal of the American Medical Association, 284(22), 2847–2849. Cooper, R. J., Hoffman, J. R., Bartlett, J. G., et al. (June 2001). Centers for Disease Control and Prevention. Principles of appropriate antibiotic use for acute pharyngitis in adults: background. Annals of Emergency Medicine. 37(6), 711–719. Corneli, H. (2001). Rapid strep tests in the emergency department: An evidence-based approach. Pediatric Emergency Care, 17(4), 272–278. Ebell, M. H., Smith, M. A., Barry, H. C., Ives, K., & Carey, M. (2000). Does this patient have strep throat? Journal of the American Medical Association, 284(22), 2912–2918. Hall, C. B. (2001). Respiratory syncytial virus and parainfluenza virus. New England Journal of Medicine, 344(25), 1917–1928. Hickner, J. M. (2001). Acute rhinosinusitis: A diagnostic and therapeutic challenge. Journal of Family Practice, 50(1), 38–40. Hickner, J. M., Bartlett, J. G., Besser, R. E., et al. (2001). American Academy of Family Physicians/American Society of Internal Medi-
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cine. Centers for Disease Control Infectious Diseases Society of America. Principles of appropriate antibiotic use for acute rhinosinusitis in adults: background. Annals of Internal Medicine, 134(6), 498–505. Kearney, K. (2001). Emergency: Epiglottis. American Journal of Nursing, 101(8), 37–38. Kernan, W. N., Viscoli, C. M., Brass, L. M., et al. (2000). Phenylpropanolamine and the risk of hemorrhagic stroke. New England Journal of Medicine, 343(25), 1826–1832. Luna, B., Drew, R. H., & Perfect, J. R. (2000). Agents for the treatment of invasive fungal infections. Otolaryngologic Clinics of North America, 33(4), 277–299. Mattila, P. (2001). Causes of tonsillar disease and frequency of tonsillectomy operations. Archives of Otolaryngology- Head & Neck Surgery, 127(1), 37–44. Piccirillo, J. F., Mager, D. E., Frisse, M. E., Brophy, R. H. & Goggin, A. (2001). Impact of first-line vs. second-line antibiotics for the treatment of acute uncomplicated sinusitis. Journal of the American Medical Association, 286(15), 1849–1856. Prasad, A. S., Fitzgerald, J. T., Bao, B., et al. (2000). Duration of symptoms and plasma cytokine levels in patients with the common cold treated with zinc acetate: A randomized, double-blind, placebocontrolled trial. Annals of Internal Medicine, 133(4), 245–252. Sly, M. (1999). Changing prevalence of allergic rhinitis and asthma. Annals of Allergy, Asthma, & Immunology, 82(3), 233–252. Snow, V., Mottur-Pilson, C., Hickner, J. M., et al. (2001). Principles of appropriate antibiotic use for acute sinusitis in adults. Annals of Internal Medicine, 134(6), 495–497. Stephenson, K. (2000). Acute and chronic pharyngitis across the lifespan. Lippincott’s Primary Care Practice. Ear, Nose, and Throat Problems, 4(5), 471–489. Stone, S., Gonzales, R., Maselli, J., & Lowenstein, S. R. (2000). Antibiotic prescribing for patients with colds, upper respiratory tract infections, and bronchitis: A national study of hospital-based emergency departments. Annals of Emergency Medicine. 36(4), 320–327. Youngs, R. (2000) Sinusitis in adults. Current Opinion in Pulmonary Medicine, 6(3), 217–220. Obstruction and Trauma of the Airway Boehlecke, B. A. (2000). Epidemiology and pathogenesis of sleepdisordered breathing. Current Opinion in Pulmonary Medicine, 6(6), 471–478. Flemons, W. W. (2002). Clinical practice. Obstructive sleep apnea. New England Journal of Medicine, 347(7), 498–504. Goldberg, R. (2000). Treatment of obstructive sleep apnea, other than with continuous positive airway pressure. Current Opinion in Pulmonary Medicine, 6(6), 496–500. Harding, S. M. (2000). Complications and consequences of obstructive sleep apnea. Current Opinion in Pulmonary Medicine, 6(6), 485–489. Krieger, A. C. & Redeker, N. S. (2002) Obstructive sleep apnea syndrome: its relationship with hypertension. Journal of Cardiovascular Nursing, 17(1), 1–11. Krishna, P., & Lee, D. (2001). Post-tonsillectomy bleeding: A metaanalysis. Laryngoscope, 111(8), 1358–1361. Liu, J., Anderson, K. E., Willging, J. P., et al. (2001). Post-tonsillectomy hemorrhage: What is it and what should be recorded? Archives of Otolaryngology—Head & Neck Surgery, 127(10), 1271–1275. Marchiondo, K. (2000). Pickwickian syndrome: The challenge of severe sleep apnea. MedSurg Nursing, 9(4), 183–188. Narkiewicz, K., Kato, M., Phillips, B. G., et al. (1999). Nocturnal continuous positive airway pressure decreases daytime sympathetic traffic in obstructive sleep apnea. Circulation, 100(23), 2332–2335. National Institutions of Health. (2000). NHLBI study shows association between sleep apnea and hypertension (Press release, 4-11-00). http://www.nhlbi.nih.gov/about/ncsdr. Nieto, F. J., Young, T. B., Lind, B. K., et al. (2000). Association of sleep-disordered breathing, sleep apnea, and hypertension in a large
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community-based study. Sleep Heart Health Study. Journal of the American Medical Association, 283(14), 1829–1836. Parker, K. P. & Dunbar, S. B. (2002). Sleep and heart failure. Journal of Cardiovascular Nursing, 17(1), 12–29. Peppard, P. E., Young, T., Palta, M., et al. (2000). Longitudinal study of moderate weight change and sleep-disordered breathing. Journal of the American Medical Association, 284(23), 3015–3021. Redeker, N. S. (2002). Why is sleep relevant to cardiovascular disease? Journal of Cardiovascular Nursing, 17(1), v–ix. Cancer of the Larynx Bauer, A. M. (2001). Current trends in surgical management of head and neck carcinomas. Nursing Clinics of North America, 36(3), 501–506. *Dropkin, M. J. (2001). Anxiety, coping strategies and coping behaviors in patients undergoing head and neck cancer surgery. Cancer Nursing, 24(2), 143–148. Finizia, C., & Bergman, B. (2001). Health-related quality of life in patients with laryngeal cancer: A post-treatment comparison of different modes of communication. Laryngoscope, 111(5), 918–923. Forastiere, A., Koch, W., Trotti, A., & Sidransky, D. (2001). Head and neck cancer. New England Journal of Medicine, 345(26), 1890–1900. Friedman, M., Landsberg, R., Pryor, S., et al. (2001). The occurrence of sleep-disordered breathing among patients with head and neck cancer. Laryngoscope, 111(11), 1917–1919. *Hemsley, B. (2001). Nursing the patient with severe communication impairment. Journal of Advanced Nursing, 35(6), 827–835. Koch, W. (2001). A fail-safe technique for endoscopic tracheoesophageal puncture. Laryngoscope, 111(9), 1663–1665. *Major, M. S., Bumpous, J. M., Flynn, M. B., & Schill, K. (2001). Quality of life after treatment for advanced laryngeal and hypopharyngeal cancer. Laryngoscope, 111(8), 1379–1382. Owen, C., et al. (2001). The psychosocial impact of head and neck cancer. Clinical Otolaryngology & Allied Sciences, 26(5), 351–356. Rose, P., & Yates, P. (2001). Quality of life experienced by patients receiving radiation treatment for cancers of the head and neck. Cancer Nursing, 24(4), 255–263. Serra, A. (2000). Tracheostomy care. Nursing Standard, 14(42), 45–55. Tamura, E. (2001). Clinical assessment of intralaryngeal ultrasonography. Laryngoscope, 111(10), 767–770. Weinstein, G. S., El-Sawy, M. M., Ruiz, C., et al. (2001). Laryngeal preservation with supracricoid partial laryngectomy results in improved quality of life when compared with total laryngectomy. Laryngoscope, 111(12), 191–199.
RESOURCES AND WEBSITES American Cancer Society, 1599 Clifton Rd., NE, Atlanta, GA 303294251; (404) 320-3333; (800) ACS-2345; http://www.cancer.org. American Lung Association, 1740 Broadway, New York, NY 100194374; (212) 315-8700; http://www.lungusa.org. American Sleep Apnea Association, 1424 K Street, NW, Suite 302, Washington, DC 20005; 202-293-3650; http://www.sleepapnea.org. International Association of Laryngectomees, 7400 N. Shadeland Ave., Suite 100, Indianapolis, IN 46250; (317) 570-4568; http://www. larynxlink.com. National Cancer Institute (NCI), Bldg. 31, 31 Center Drive, MSC 2580, Bethesda, MD 20892-2580; http://cancernet.nci.nih.gov. National Institute of Allergy and Infectious Disease, Building 31, 31 Center Drive MSC 2520, Bethesda, MD 20892-2520; http://www. niaid.nih.gov. National Heart, Lung, and Blood Institute (NHBLI), National Institutes of Health, Bldg. 31, Rm. 4A21, Bethesda, MD 20892; 301592-8573 800-575-9355; http://www.nhlbi.nih.gov. National Sleep Foundation, 1522 K Street NW, Suite 500, Washington, DC 20005; 202-437-3471; Fax: 202-347-3472; http://www. sleepfoundation.org. Voice Center at Eastern Virginia Medical School, Norfolk, VA 23507; http://www.voice-center.com.
Chapter
23 ●
Management of Patients With Chest and Lower Respiratory Tract Disorders
LEARNING OBJECTIVES
●
On completion of this chapter, the learner will be able to: 1. Identify patients at risk for atelectasis and nursing interventions 2. 3. 4. 5. 6. 7. 8. 9. 10. 11.
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related to its prevention and management. Compare the various pulmonary infections with regard to causes, clinical manifestations, nursing management, complications, and prevention. Use the nursing process as a framework for care of the patient with pneumonia. Relate pleurisy, pleural effusion, and empyema to pulmonary infection. Describe smoking and air pollution as causes of pulmonary disease. Relate the therapeutic management techniques of acute respiratory distress syndrome to the underlying pathophysiology of the syndrome. Describe risk factors for and measures appropriate for prevention and management of pulmonary embolism. Describe preventive measures appropriate for controlling and eliminating the problem of occupational lung disease. Discuss the modes of therapy and related nursing management for patients with lung cancer. Describe the complications of chest trauma and their clinical manifestations and nursing management. Describe nursing measures to prevent aspiration.
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onditions affecting the lower respiratory tract range from acute problems to long-term chronic disorders. Many of these disorders are serious and often life-threatening. The patient with a lower respiratory tract disorder requires care from nurses with astute assessment and clinical management skills as well as an understanding of the impact of the disorder on the patient’s quality of life and ability to carry out usual activities of daily living. Patient and family teaching is an important nursing intervention in the management of all lower respiratory tract disorders.
Atelectasis Atelectasis refers to closure or collapse of alveoli and often is described in relation to x-ray findings and clinical signs and symptoms. Atelectasis may be acute or chronic and may cover a broad range of pathophysiologic changes, from microatelectasis (which is not detectable on chest x-ray) to macroatelectasis with loss of segmental, lobar, or overall lung volume. The most commonly described atelectasis is acute atelectasis, which occurs frequently in the postoperative setting or in people who are immobilized and have a shallow, monotonous breathing pattern. Excess secretions or mucus plugs may also cause obstruction of airflow and result in atelectasis in an area of the lung. Atelectasis also is observed in patients with a chronic airway obstruction that impedes or blocks air flow to an area of the lung (eg, obstructive atelectasis in the patient with lung cancer that is invading or compressing the airways). This type of atelectasis is more insidious and slower in onset.
Pathophysiology Atelectasis may occur in the adult as a result of reduced alveolar ventilation or any type of blockage that impedes the passage of air to and from the alveoli that normally receive air through the
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bronchi and network of airways. The trapped alveolar air becomes absorbed into the bloodstream, but outside air cannot replace the absorbed air because of the blockage. As a result, the isolated portion of the lung becomes airless and the alveoli collapse. This may occur with altered breathing patterns, retained secretions, pain, alterations in small airway function, prolonged supine positioning, increased abdominal pressure, reduced lung volumes due to musculoskeletal or neurologic disorders, restrictive defects, and specific surgical procedures (eg, upper abdominal, thoracic, or open heart surgery). Persistent low lung volumes, secretions or a mass obstructing or impeding airflow, and compression of lung tissue may all cause collapse or obstruction of the airways, which leads to atelectasis. The postoperative patient is at high risk for atelectasis because of the numerous respiratory changes that may occur. A monotonous low tidal breathing pattern may cause airway closure and alveolar collapse. This results from the effects of anesthesia or analgesic agents, supine positioning, splinting of the chest wall because of pain, and abdominal distention. The postoperative patient may also have secretion retention, airway obstruction, and an impaired cough reflex or may be reluctant to cough because of pain. Figure 23-1 shows the pathogenic mechanisms and consequences of acute atelectasis in the postoperative patient. Atelectasis resulting from bronchial obstruction by secretions may occur in patients with impaired cough mechanisms (eg, postoperative, musculoskeletal or neurologic disorders) or in debilitated, bedridden patients. Atelectasis may also result from excessive pressure on the lung tissue, which restricts normal lung expansion on inspiration. Such pressure may be produced by fluid accumulating within the pleural space (pleural effusion), air in the pleural space (pneumothorax), or blood in the pleural space (hemothorax). The pleural space is the area between the parietal and the visceral pleurae. Pressure may also be produced
Glossary acute respiratory distress syndrome (ARDS): nonspecific pulmonary response to a variety of pulmonary and nonpulmonary insults to the lung; characterized by interstitial infiltrates, alveolar hemorrhage, atelectasis, decreased compliance, and refractory hypoxemia asbestosis: diffuse lung fibrosis resulting from exposure to asbestos fibers atelectasis: collapse or airless condition of the alveoli caused by hypoventilation, obstruction to the airways, or compression central cyanosis: bluish discoloration of the skin or mucous membranes due to hemoglobin carrying reduced amounts of oxygen consolidation: lung tissue that has become more solid in nature due to collapse of alveoli or infectious process (pneumonia) cor pulmonale: “heart of the lungs”; enlargement of the right ventricle from hypertrophy or dilation or as a secondary response to disorders that affect the lungs empyema: accumulation of purulent material in the pleural space fine-needle aspiration: insertion of a needle through the chest wall to obtain cells of a mass or tumor; usually performed under fluoroscopy or chest CT guidance
hemoptysis: the coughing up of blood from the lower respiratory tract hemothorax: partial or complete collapse of the lung due to blood accumulating in the pleural space; may occur after surgery or trauma induration: an abnormally hard lesion or reaction, as in a positive tuberculin skin test nosocomial: pertaining to or originating from a hospitalization; not present at the time of hospital admission open lung biopsy: biopsy of lung tissue performed through a limited thoracotomy incision orthopnea: shortness of breath when reclining or in the supine position pleural effusion: abnormal accumulation of fluid in the pleural space pleural friction rub: localized grating or creaking sound caused by the rubbing together of inflamed parietal and visceral pleurae pleural space: the area between the parietal and visceral pleurae; a potential space pneumothorax: partial or complete collapse of the lung due to positive pressure in the pleural space
pulmonary edema: increase in the amount of extravascular fluid in the lung pulmonary embolism: obstruction of the pulmonary vasculature with an embolus; embolus may be due to blood clot, air bubbles, or fat droplets purulent: consisting of, containing, or discharging pus restrictive lung disease: disease of the lung that causes a decrease in lung volumes tension pneumothorax: pneumothorax characterized by increasing positive pressure in the pleural space with each breath; this is an emergency situation and the positive pressure needs to be decompressed or released immediately thoracentesis: insertion of a needle into the pleural space to remove fluid that has accumulated and decrease pressure on the lung tissue; may also be used diagnostically to identify potential causes of a pleural effusion transbronchial: through the bronchial wall, as in a transbronchial lung biopsy ventilation–perfusion ratio: the ratio between ventilation and perfusion in the lung; matching of ventilation to perfusion optimizes gas exchange
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Physiology/Pathophysiology
FIGURE 23-1 Relationship of risk factors, pathogenic mechanisms, and consequences of acute atelectasis in the postoperative patient. COPD, chronic obstructive pulmonary disease; BMI, body mass index; FRC, functional residual . . capacity; diaphragm fx, diaphragm function; ASA, American Society of Anesthesiology physical status; V /Q , ventilation-perfusion ratio. From the work of Jo Ann Brooks-Brunn, DNS, RN, FAAN, FCCP, Indiana University Medical Center, Indianapolis.
by a pericardium distended with fluid (pericardial effusion), tumor growth within the thorax, or an elevated diaphragm.
Clinical Manifestations The development of atelectasis usually is insidious. Signs and symptoms include cough, sputum production, and low-grade fever. Fever is universally cited as a clinical sign of atelectasis, but there are few data to support this. Most likely the fever that accompanies atelectasis is due to infection or inflammation distal to the obstructed airway. In acute atelectasis involving a large amount of lung tissue (lobar atelectasis), marked respiratory distress may be observed. In addition to the above signs and symptoms, dyspnea, tachycar-
dia, tachypnea, pleural pain, and central cyanosis (a bluish skin hue that is a late sign of hypoxemia) may be anticipated. The patient characteristically has difficulty breathing in the supine position and is anxious. Signs and symptoms of chronic atelectasis are similar to those of acute atelectasis. Because the alveolar collapse is chronic, infection may occur distal to the obstruction. Thus, the signs and symptoms of a pulmonary infection also may be present.
Assessment and Diagnostic Findings Decreased breath sounds and crackles are heard over the affected area. In addition, chest x-ray findings may reveal patchy infiltrates or consolidated areas. In the patient who is confined to bed,
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atelectasis is usually diagnosed by chest x-ray or identified by physical assessment in the dependent, posterior, basilar areas of the lungs. Depending on the degree of hypoxemia, pulse oximetry (SpO2) may demonstrate a low saturation of hemoglobin with oxygen (less than 90%) or a lower-than-normal partial pressure of arterial oxygen (PaO2).
Prevention Nursing measures to prevent atelectasis include frequent turning, early mobilization, and strategies to expand the lungs and to manage secretions. Deep-breathing maneuvers (at least every 2 hours) assist in preventing and treating atelectasis. The performance of these maneuvers requires a patient who is alert and cooperative. Patient education and reinforcement are key to the success of these interventions. The use of incentive spirometry or voluntary deep breathing enhances lung expansion, decreases the potential for airway closure, and may generate a cough. Secretion management techniques may include directed cough, suctioning, aerosol nebulizer treatments followed by chest physical therapy (postural drainage and chest percussion), or bronchoscopy. In some settings, a metered-dose inhaler (MDI) is used to dispense a bronchodilator rather than an aerosol nebulizer treatment. Chart 23-1 summarizes measures to prevent atelectasis.
Management The goal in treating the patient with atelectasis is to improve ventilation and remove secretions. The strategies to prevent atelectasis, which include frequent turning, early ambulation, lung volume expansion maneuvers (eg, deep-breathing exercises, incentive spirometry), and coughing also serve as the first-line measures to minimize or treat atelectasis by improving ventilation. In patients who do not respond to first-line measures or who cannot perform deep-breathing exercises, other treatments such as positive expiratory pressure or PEP therapy (a simple mask and oneway valve system that provides varying amounts of expiratory resistance [usually 5 to 15 cm H2O]), continuous or intermittent positive pressure-breathing (IPPB), or bronchoscopy may be used. Although IPPB may be used in some settings, few data support its use in the postoperative setting (Duffy & Farley, 1993). Before initiating more complex, costly, and labor-intensive therapies, the nurse should ask several questions: • Has the patient been given an adequate trial of deepbreathing exercises?
Chart 23-1
Preventing Atelectasis
• Change patient’s position frequently, especially from supine to • • • • • •
upright position, to promote ventilation and prevent secretions from accumulating. Encourage early mobilization from bed to chair followed by early ambulation. Encourage appropriate deep breathing and coughing to mobilize secretions and prevent them from accumulating. Teach/reinforce appropriate technique for incentive spirometry. Administer prescribed opioids and sedatives judiciously to prevent respiratory depression. Perform postural drainage and chest percussion, if indicated. Institute suctioning to remove tracheobronchial secretions, if indicated.
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• Has the patient received adequate education, supervision, and coaching to carry out the deep-breathing exercises?
• Have other factors been evaluated that may impair ventila-
tion or prohibit a good patient effort (eg, lack of turning, mobilization; excessive pain; excessive sedation)?
If the cause of atelectasis is bronchial obstruction from secretions, the secretions must be removed by coughing or suctioning to permit air to re-enter that portion of the lung. Chest physical therapy (chest percussion and postural drainage) may also be used to mobilize secretions. Nebulizer treatments with a bronchodilator medication or sodium bicarbonate may be used to assist the patient in the expectoration of secretions. If respiratory care measures fail to remove the obstruction, a bronchoscopy is performed. Severe or massive atelectasis may lead to acute respiratory failure, especially in a patient with underlying lung disease. Endotracheal intubation and mechanical ventilation may be necessary. Prompt treatment reduces the risk for acute respiratory failure or pneumonia. If atelectasis has resulted from compression of lung tissue, the goal is to decrease the compression. With a large pleural effusion that is compressing lung tissue and causing alveolar collapse, treatment may include thoracentesis, removal of the fluid by needle aspiration, or insertion of a chest tube. The measures to increase lung expansion described above also are used. Management of chronic atelectasis focuses on removing the cause of the obstruction of the airways or the compression of the lung tissue. For example, bronchoscopy may be used to open an airway obstructed by lung cancer or a nonmalignant lesion, and the procedure may involve cryotherapy or laser therapy. The goal is to reopen the airways and provide ventilation to the collapsed area. In some cases, surgical management may be indicated.
Respiratory Infections ACUTE TRACHEOBRONCHITIS Acute tracheobronchitis, an acute inflammation of the mucous membranes of the trachea and the bronchial tree, often follows infection of the upper respiratory tract. A patient with a viral infection has decreased resistance and can readily develop a secondary bacterial infection. Thus, adequate treatment of upper respiratory tract infection is one of the major factors in the prevention of acute bronchitis. Aside from infection, inhalation of physical and chemical irritants, gases, and other air contaminants can also cause acute bronchial irritation.
Pathophysiology In acute tracheobronchitis, the inflamed mucosa of the bronchi produces mucopurulent sputum, often in response to Streptococcus pneumoniae, Haemophilus influenzae, and Mycoplasma pneumoniae. In addition, a fungal infection (eg, Aspergillus tracheobronchitis) may also cause tracheobronchitis. A sputum culture is essential to identify the specific causative organism.
Clinical Manifestations Initially, the patient has a dry, irritating cough and expectorates a scanty amount of mucoid sputum. The patient complains of sternal soreness from coughing and has fever or chills and night sweats, headache, and general malaise. As the infection progresses, the patient may be short of breath, have noisy inspiration and expiration (inspiratory stridor and expiratory wheeze), and
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produce purulent (pus-filled) sputum. With severe tracheobronchitis, blood-streaked secretions may be expectorated as a result of the irritation of the mucosa of the airways.
Medical Management Antibiotic treatment may be indicated depending on the symptoms, sputum purulence, and results of the sputum culture. Antihistamines are usually not prescribed because they may cause excessive drying and make secretions more difficult to expectorate. Expectorants may be prescribed, although their efficacy is questionable. Fluid intake is increased to thin the viscous and tenacious secretions. Copious, purulent secretions that cannot be cleared by coughing place the patient at risk for increasing airway obstruction and the development of a more severe lower respiratory tract infection, such as pneumonia. Suctioning and bronchoscopy may be needed to remove secretions. Rarely, endotracheal intubation may be required in cases of acute tracheobronchitis leading to acute respiratory failure. This may be necessary for patients who are severely debilitated or who have coexisting diseases that also impair the respiratory system. In most cases, treatment of tracheobronchitis is largely symptomatic. The patient is advised to rest. Increasing the vapor pressure (moisture content) in the air will reduce irritation. Cool vapor therapy or steam inhalations may help relieve laryngeal and tracheal irritation. Moist heat to the chest may relieve the soreness and pain. Mild analgesics or antipyretics may be indicated.
Nursing Management Acute tracheobronchitis is frequently treated in the home setting. A primary nursing function is to encourage bronchial hygiene, such as increasing fluid intake and directed coughing to remove secretions. The nurse should encourage and assist the patient to sit up frequently to cough effectively and to prevent retention of mucopurulent sputum. If the patient is treated with antibiotics for an underlying infection, it is important to emphasize the need to complete the full course of antibiotics prescribed. Fatigue is a consequence of tracheobronchitis; therefore, the nurse must caution the patient against overexertion, which can induce a relapse or exacerbation of the infection.
PNEUMONIA Pneumonia is an inflammation of the lung parenchyma that is caused by a microbial agent. “Pneumonitis” is a more general term that describes an inflammatory process in the lung tissue that may predispose a patient to or place a patient at risk for microbial invasion. Pneumonia is the most common cause of death from infectious diseases in the United States. It is the seventh leading cause of death in the United States for all ages and both genders, resulting in almost 70,000 deaths per year. In persons 65 years of age and older, it is the fifth leading cause of death (National Center for Health Statistics, 2000; Minino & Smith, 2001). It is treated extensively on both an inpatient and outpatient basis. Bacteria commonly enter the lower airway but do not cause pneumonia in the presence of an intact host defense mechanism. When pneumonia does occur, it is caused by various microorganisms, including bacteria, mycobacteria, chlamydiae, mycoplasma, fungi, parasites, and viruses. Several systems are used to classify pneumonias. Classically, pneumonia has been categorized into one of four categories: bacterial or typical, atypical, anaerobic/ cavitary, and opportunistic. However, there is overlap in the microorganisms thought to be responsible for typical and atypical pneu-
monias. A more widely used classification scheme categorizes the major pneumonias as community-acquired pneumonia, hospitalacquired pneumonia, pneumonia in the immunocompromised host, and aspiration pneumonia (Table 23-1). There is overlap in how specific pneumonias are classified because they may occur in differing settings. Community-acquired pneumonia (CAP) occurs either in the community setting or within the first 48 hours of hospitalization or institutionalization. The need for hospitalization for CAP depends on the severity of the pneumonia. The agents that most frequently cause CAP requiring hospitalization are S. pneumoniae, H. influenzae, Legionella, Pseudomonas aeruginosa, and other gramnegative rods. The specific etiologic agent of CAP is identified in about 50% of the cases. The absence of a responsible caregiver in the home may be another indication for hospitalization. More than 5.5 million people develop CAP and as many as 1.1 million require hospitalization each year (Centers for Disease Control and Prevention [CDC], 1997; Marston, Plouffe, File et al., 1997). Pneumonia caused by S. pneumoniae (pneumococcus) is the most common CAP in people younger than 60 without comorbidity and in those older than 60 with comorbidity. It is most prevalent during the winter and spring, when upper respiratory tract infections are most frequent. S. pneumoniae is a gram-positive, capsulated, nonmotile coccus that resides naturally in the upper respiratory tract. The organism colonizes the upper respiratory tract and can cause the following types of illnesses: disseminated invasive infections, pneumonia and other lower respiratory tract infections, and upper respiratory tract infections, including otitis media and sinusitis (CDC, 1998). It may occur as a lobar or bronchopneumonic form in patients of any age and may follow a recent respiratory illness. Mycoplasma pneumonia, another type of CAP, occurs most often in older children and young adults and is spread by infected respiratory droplets through person-to-person contact. Patients can be tested for mycoplasma antibodies. The inflammatory infiltrate is primarily interstitial rather than alveolar. It spreads throughout the entire respiratory tract, including the bronchioles, and has the characteristics of a bronchopneumonia. Earache and bullous myringitis are common. Impaired ventilation and diffusion may occur. H. influenzae is another cause of CAP. It frequently affects elderly people or those with comorbid illnesses (eg, chronic obstructive pulmonary disease [COPD], alcoholism, diabetes mellitus). The presentation of this pneumonia is indistinguishable from that of other forms of bacterial CAP. The presentation may be subacute, with cough or low-grade fever for weeks before diagnosis. Chest x-rays may reveal multilobar, patchy bronchopneumonia or areas of consolidation (tissue that solidifies as a result of collapsed alveoli or pneumonia). Viruses are the most common cause of pneumonia in infants and children but are relatively uncommon causes of CAP in adults. The chief causes of viral pneumonia in the immunocompetent adult are influenza viruses types A and B, adenovirus, parainfluenza virus, coronavirus, and varicella-zoster virus. In immunocompromised adults, cytomegalovirus is the most common viral pathogen, followed by herpes simplex virus, adenovirus, and respiratory syncytial virus. The acute stage of a viral respiratory infection occurs within the ciliated cells of the airways. This is followed by infiltration of the tracheobronchial tree. With pneumonia, the inflammatory process extends into the alveolar area, resulting in edema and exudation. The clinical signs and symptoms of a viral pneumonia are often difficult to distinguish from those of a bacterial pneumonia. (text continues on page 524)
Chapter 23
Table 23-1 TYPE
Management of Patients With Chest and Lower Respiratory Tract Disorders
521
• Commonly Encountered Pneumonias ORGANISM RESPONSIBLE
Community-Acquired Pneumonia Streptococcal Streptococcus pneumonia pneumoniae (pneumococcal)
Haemophilus influenzae
Haemophilus influenzae
Legionnaires’ disease
Legionella pneumophila
EPIDEMIOLOGY
CLINICAL FEATURES
TREATMENT
COMMENTS
Highest occurrence in winter months. Incidence greatest in the elderly and in patients with COPD, heart failure, alcoholism, asplenia, following influenza. Leading infectious cause of illness worldwide among young children, persons with underlying chronic health conditions, and the elderly. Death occurs in 14% of hospitalized adults with invasive disease. Incidence greatest in alcoholics, the elderly, patients in chronic care facilities and nursing homes, patients with diabetes or COPD, and children 30%
Daily medications: • Anti-inflammatory: inhaled corticosteroid (high dose) AND • Long-acting bronchodilator: either long-acting inhaled beta2-agonist, sustained-release theophylline, or long-acting beta2-agonist tablets AND • Corticosteroid tablets or syrup long term (2 mg/ kg/day, generally do not exceed 60 mg per day).
STEP 3 Moderate Persistent
• Daily symptoms • Daily use of inhaled shortacting beta2-agonist • Exacerbations affect activity • Exacerbations ≥2 times a week; may last days
>1 time a week
• FEV1 or PEF 60% to 80% predicted • PEF variability >30%
STEP 2 Mild Persistent
• Symptoms >2 times a week but 2 times a month
• FEV1 or PEF ≥80% predicted • PEF variability 20%–30%
Daily medication: • Either – Anti-inflammatory: inhaled corticosteroid (medium dose) OR – Inhaled corticosteroid (low–medium dose) and add a long-acting bronchodilator, especially for nighttime symptoms; either long-acting inhaled beta2-agonist, sustained-release theophylline, or long-acting beta2-agonist tablets. • If needed – Anti-inflammatory: inhaled corticosteroids (medium–high dose) AND – Long-acting bronchodilator, especially for nighttime symptoms; either long-acting inhaled beta2-agonist, sustained-release theophylline, or long-acting beta2-agonist tablets. Daily medication: • Anti-inflammatory: either inhaled corticosteroid (low doses) or cromolyn or nedocromil (children usually begin with a trial of cromolyn or nedocromil).
Step 1 actions plus: • Teach selfmonitoring • Refer to group education if available • Review and update selfmanagement plan
(continued)
Chapter 24
Table 24-3
591
• Stepwise Approach for Managing Asthma in Adults and Children Over 5 Years Old (Continued) SYMPTOMS**
STEP 1 Mild Intermittent
Management of Patients With Chronic Obstructive Pulmonary Disease
• Symptoms ≤2 times a week • Asymptomatic and normal PEF between exacerbations • Exacerbations brief (from a few hours to a few days); intensity may vary
NIGHTTIME SYMPTOMS
≤2 times a month
LUNG FUNCTION
• FEV1 or PEF ≥80% predicted • PEF variability 0.60 PaO2 > 50 mm Hg with pH < 7.25 Vital capacity < 2 times tidal volume Negative inspiratory force < 25 cm H2O Respiratory rate > 35/min
volume-cycled. Another type of positive-pressure ventilator used for selected patients is noninvasive positive-pressure ventilation. PRESSURE-CYCLED VENTILATORS The pressure-cycled ventilator ends inspiration when a preset pressure has been reached. In other words, the ventilator cycles on, delivers a flow of air until it reaches a predetermined pressure, then cycles off. Its major limitation is that the volume of air or oxygen can vary as the patient’s airway resistance or compliance changes. As a result, the tidal volume delivered may be inconsistent, possibly compromising ventilation. Consequently, in adults, pressure-cycled ventilators are intended only for short-term use. The most common type is the IPPB machine (see previous discussion of IPPB). TIME-CYCLED VENTILATORS Time-cycled ventilators terminate or control inspiration after a preset time. The volume of air the patient receives is regulated by the length of inspiration and the flow rate of the air. Most ventilators have a rate control that determines the respiratory rate, but pure time-cycling is rarely used for adults. These ventilators are used in newborns and infants.
A
FIGURE 25-6
VOLUME-CYCLED VENTILATORS Volume-cycled ventilators are by far the most commonly used positive-pressure ventilators today (Fig. 25-6). With this type of ventilator, the volume of air to be delivered with each inspiration is preset. Once this preset volume is delivered to the patient, the ventilator cycles off and exhalation occurs passively. From breath to breath, the volume of air delivered by the ventilator is relatively constant, ensuring consistent, adequate breaths despite varying airway pressures. NONINVASIVE POSITIVE-PRESSURE VENTILATION Positive-pressure ventilation can be given via facemasks that cover the nose and mouth, nasal masks, or other nasal devices. This eliminates the need for endotracheal intubation or tracheostomy and decreases the risk for nosocomial infections such as pneumonia. The most comfortable mode for the patient is pressurecontrolled ventilation with pressure support. This eases the work of breathing and enhances gas exchange. The ventilator can be set with a minimum backup rate for patients with periods of apnea. Patients are considered candidates for noninvasive ventilation if they have acute or chronic respiratory failure, acute pulmonary edema, COPD, or chronic heart failure with a sleep-related breathing disorder. The device also may be used at home to improve tissue oxygenation and to rest the respiratory muscles while the patient sleeps at night. It is contraindicated for those who have experienced respiratory arrest, serious dysrhythmias, cognitive impairment, or head or facial trauma. Noninvasive ventilation may also be used for patients at the end of life and those who do not want endotracheal intubation but may need short- or long-term ventilatory support (Scanlan, Wilkins & Stoller, 1999). Bilevel positive airway pressure (bi-PAP) ventilation offers independent control of inspiratory and expiratory pressures while providing pressure support ventilation. It delivers two levels of
B
Control panels of positive pressure ventilators in current use illustrate functions made possible by technologic advances. (A) Bear 1000 ventilator. Courtesy Bear Medical Systems. (B) Servo Ventilator 300 with Automode allows weaning to begin with the patient still intubated. Courtesy Siemens Medical Systems, Inc.
Chapter 25
617
ASSESSING THE EQUIPMENT
positive airway pressure provided via a nasal or oral mask, nasal pillow, or mouthpiece with a tight seal and a portable ventilator. Each inspiration can be initiated either by the patient or by the machine if it is programmed with a backup rate. The backup rate ensures that the patient will receive a set number of breaths per minute (Perkins & Shortall, 2000). Bi-PAP is most often used for patients who require ventilatory assistance at night, such as those with severe COPD or sleep apnea. Tolerance is variable; bi-PAP is usually most successful with highly motivated patients.
The ventilator needs to be assessed to make sure that it is functioning properly and that the settings are appropriate. Even though the nurse is not primarily responsible for adjusting the settings on the ventilator or measuring ventilator parameters (usually the responsibility of the respiratory therapist), the nurse is responsible for the patient and therefore needs to evaluate how the ventilator affects the patient’s overall status. In monitoring the ventilator, the nurse should note the following:
ADJUSTING THE VENTILATOR
• Type of ventilator (such as volume-cycled, pressure-cycled,
The ventilator is adjusted so that the patient is comfortable and breathes “in sync” with the machine. Minimal alteration of the normal cardiovascular and pulmonary dynamics is desired. Modes of mechanical ventilation are described in Figure 25-7. If the volume ventilator is adjusted appropriately, the patient’s arterial blood gas values will be satisfactory and there will be little or no cardiovascular compromise. Chart 25-12 discusses how to achieve adequate mechanical ventilation for each patient.
1000
Respiratory Care Modalities
negative-pressure)
• Controlling mode (such as controlled ventilation, assist– • •
control ventilation, synchronized intermittent mandatory ventilation) Tidal volume and rate settings (tidal volume is usually 10 to 15 mL/kg; rate is usually 12 to 16/min) FiO2 (fraction of inspired oxygen) setting
A Flow in the controlled ventilation mode. A preset volume of gas is delivered to the patient under positive pressure while spontaneous patient respiratory effort is “locked out.”
Inspiration Expiration
Volume (cc) 0 A CONTROLLED VENTILATION
B Gas flow in the assist/control ventilation mode. In this mode, a preset volume of gas is delivered to the patient at a preset rate, but the patient may trigger a ventilator breath with negative inspiratory effort.
1000 Volume (cc) 0 B ASSIST/CONTROLLED VENTILATION (A/C) 1000 Volume (cc) 0 C SYNCHRONIZED INTERMITTENT MANDATORY VENTILATION (SIMV)
D Airway pressure with varying levels of positive end-expiratory pressure (PEEP). Note that at end expiration, the airway is not allowed to return to zero. (FRC: functional residual capacity.)
40 Pressure (cm H2O) +X Baseline FRC elevated 0 D POSITIVE END EXPIRATORY PRESSURE (PEEP) I E + 0 – E CONTINUOUS POSITIVE AIRWAY PRESSURE (CPAP)
E Spontaneous ventilation with continous positive airway pressure (CPAP). This ventilatory adjunct is used only with spontaneous SV ventilation; the patient breathes spontaneously through the ventilawith tor at an elevated baseline pressure throughout the breathing cycle. CPAP
E
I
SV with PS
+ 0 – F PRESSURE SUPPORT (PS) Inspiration
FIGURE 25-7
Exhalation
C Gas flow in the synchronized intermittent mandatory ventilation (SIMV) mode. A preset minimum number of breaths are synchronously delivered to the patient but the patient may also take spontaneous breaths of varying volumes. Note how inspiratory and expiratory pressures differ between spontaneous and ventilator breaths.
Patient-triggered breath
Modes of mechanical ventilation with air flow waveforms.
F Spontaneous ventilation with pressure support (PS). The patient breathes spontaneously with pressure assistance to each spontaneous inspiration.
Unit 5
618
Chart 25-12
GAS EXCHANGE AND RESPIRATORY FUNCTION
Initial Ventilator Settings
The following guide is an example of the steps involved in operating a mechanical ventilator. The nurse, in collaboration with the respiratory therapist, always reviews the manufacturer’s instructions, which vary according to the equipment, before beginning mechanical ventilation. 1. Set the machine to deliver the tidal volume required (10 to 15 mL/kg). 2. Adjust the machine to deliver the lowest concentration of oxygen to maintain normal PaO2 (80 to 100 mm Hg). This setting may be high initially but will gradually be reduced based on arterial blood gas results. 3. Record peak inspiratory pressure. 4. Set mode (assist–control or synchronized intermittent mandatory ventilation) and rate according to physician order. (See the glossary for definitions of modes of mechanical ventilation.) Set PEEP and pressure support if ordered. 5. Adjust sensitivity so that the patient can trigger the ventilator with a minimal effort (usually 2 mm Hg negative inspiratory force). 6. Record minute volume and measure carbon dioxide partial pressure (PCO2), pH, and PO2 after 20 minutes of continuous mechanical ventilation. 7. Adjust setting (FiO2 and rate) according to results of arterial blood gas analysis to provide normal values or those set by the physician. 8. If the patient suddenly becomes confused or agitated or begins bucking the ventilator for some unexplained reason, assess for hypoxia and manually ventilate on 100% oxygen with a resuscitation bag.
into two categories: ventilator problems and patient problems. In either case, the patient must be supported while the problem is identified and corrected. Ventilator complications include cardiovascular compromise, pneumothorax, and pulmonary infection. These problems, their probable causes, and solutions are listed in Table 25-2. BUCKING THE VENTILATOR The patient is “in sync” with the ventilator when thoracic expansion coincides with the inspiratory phase of the machine and exhalation occurs passively. The patient is said to fight or buck the ventilator when out of phase with the machine. This is manifested when the patient attempts to breathe out during the ventilator’s mechanical inspiratory phase or when there is jerky and increased abdominal muscle effort. The following factors contribute to this problem: anxiety, hypoxia, increased secretions, hypercapnia, inadequate minute volume, and pulmonary edema. These problems must be corrected before resorting to the use of paralyzing agents to reduce bucking; otherwise, the underlying problem is simply masked and the patient’s condition will continue to deteriorate. Muscle relaxants, tranquilizers, analgesic agents, and paralyzing agents are sometimes administered to patients receiving mechanical ventilation. Their purpose is ultimately to increase the patient–machine synchrony by decreasing the patient’s anxiety, hyperventilation, or excessive muscle activity. The selection and dose of the appropriate medication are determined carefully and are based on the patient’s requirements and the cause of his or her restlessness. Paralyzing agents are always used as a last resort, and always in conjunction with a sedative medication.
• Inspiratory pressure reached and pressure limit (normal is
Nursing Management
•
PROMOTING HOME AND COMMUNITY-BASED CARE Increasingly, patients are being cared for in extended care facilities or at home while on mechanical ventilators, with tracheostomy tubes, or on oxygen therapy. Patients receiving home ventilator care usually have chronic neuromuscular conditions or COPD.
• • • • • • •
!
15 to 20 cm H2O; this increases if there is increased airway resistance or decreased compliance) Sensitivity (a 2-cm H2O inspiratory force should trigger the ventilator) Inspiratory-to-expiratory ratio (usually 1⬊3 [1 second of inspiration to 3 seconds of expiration] or 1⬊2) Minute volume (tidal volume × respiratory rate, usually 6 to 8 L/min) Sigh settings (usually 1.5 times the tidal volume and ranging from 1 to 3 per hour), if applicable Water in the tubing, disconnection or kinking of the tubing Humidification (humidifier filled with water) and temperature Alarms (turned on and functioning properly) PEEP and/or pressure support level, if applicable. PEEP is usually 5 to 15 cm H2O NURSING ALERT If the ventilator system malfunctions and the problem cannot be identified and corrected immediately, the nurse must ventilate the patient with a manual resuscitation bag until the problem is resolved.
PROBLEMS WITH MECHANICAL VENTILATION Because of the seriousness of the patient’s condition and the highly complex and technical nature of mechanical ventilation, a number of problems or complications can occur. Such situations fall
Teaching Patients Self-Care. Caring for the patient with mechanical ventilator support at home can be accomplished successfully, but the family must be emotionally, educationally, and physically able to assume the role of primary caregiver. A home care team consisting of the nurse, physician, respiratory therapist, social service or home care agency, and equipment supplier is needed. The home is evaluated to determine if the electrical equipment needed can be operated safely. A summary of the basic assessment criteria needed for successful home care is presented in Chart 25-13. Once the decision is made to initiate mechanical ventilation at home, the nurse prepares the patient and family for home care. It is important to teach them about the ventilator, suctioning, tracheostomy care, signs of pulmonary infection, cuff inflation and deflation, and assessment of vital signs. Teaching often begins in the hospital and continues at home. Nursing responsibilities include evaluating the patient’s and family’s understanding of the information presented. The nurse teaches the family cardiopulmonary resuscitation, including mouth-to-tracheostomy tube (instead of mouth-tomouth) breathing. The nurse also explains how to handle a power failure, which usually involves converting the ventilator from an electrical power source to a battery power source. Conversion is
Chapter 25
Table 25-2
Respiratory Care Modalities
619
• Troubleshooting Ventilator Problems
PROBLEM
CAUSE
SOLUTION
Ventilator Increase in peak airway pressure
Coughing or plugged airway tube
Suction airway for secretions, empty condensation fluid from circuit. Adjust sensitivity. Manually ventilate patient. Assess for hypoxia or bronchospasm. Check arterial blood gas values. Sedate only if necessary. Check tubing; reposition patient; insert oral airway if necessary. Manually ventilate patient; notify physician. Clear secretions. None Check entire ventilator circuit for patency. Correct leak.
Patient “bucking” ventilator Decreasing lung compliance
Tubing kinked
Decrease in pressure or loss of volume Patient Cardiovascular compromise
Pneumothorax Atelectasis or bronchospasm Increase in compliance Leak in ventilator or tubing; cuff on tube/ humidifier not tight Decrease in venous return due to application of positive pressure to lungs
Barotrauma/pneumothorax
Application of positive pressure to lungs; high mean airway pressures lead to alveolar rupture
Pulmonary infection
Bypass of normal defense mechanisms; frequent breaks in ventilator circuit; decreased mobility; impaired cough reflex
Chart 25-13
• ASSESSMENT
Criteria for Successful Home Ventilator Care The decision to proceed with home ventilation therapy is usually based on the following parameters. Patient Criteria • The patient has chronic underlying pulmonary abnormalities. • The patient’s clinical pulmonary status is stable. • The patient is willing to go home on mechanical ventilation. Home Criteria • The home environment is conducive to care of the patient. • The electrical facilities are adequate to operate all equipment safely. • The home environment is controlled, without drafts in cold weather and with proper ventilation in warm weather. • Space is available for cleaning and storing ventilator equipment. Family Criteria • Family members are competent, dependable, and willing to spend the time required for proper training with available professional support. • Family members understand the diagnosis and prognosis. • Family has sufficient financial and supportive resources.
Assess for adequate volume status by measuring heart rate, blood pressure, central venous pressure, pulmonary capillary wedge pressure, and urine output. Notify physician if values are abnormal. Notify physician. Prepare patient for chest tube insertion. Avoid high pressure settings for patients with COPD, ARDS, or history of pneumothorax. Use meticulous aseptic technique. Provide frequent mouth care. Optimize nutritional status.
automatic in most types of home ventilators and lasts approximately 1 hour. The nurse instructs the family on using a manual self-inflation bag should it be necessary. Some of the patient’s and family’s responsibilities are listed in Chart 25-14. Continuing Care. A home care nurse monitors and evaluates how well the patient and family are adapting to providing care in the home. The nurse also assesses the adequacy of ventilation and oxygenation as well as airway patency. The nurse addresses any unique adaptation problems the patient may have and listens to the patient’s and family’s anxieties and frustrations, offering support and encouragement where possible. The home care nurse helps identify and contact community resources that may assist in home management of the patient with mechanical ventilation. The technical aspects of the ventilator are managed by vendor follow-up. A respiratory therapist usually is assigned to the patient and makes frequent home visits to evaluate the patient and perform a maintenance check of the ventilator. Transportation services are identified should the patient require transportation in an emergency. These arrangements must be made before an emergency arises. Providing the opportunity for ventilator-dependent patients to return home to live with their families in familiar surroundings can be a positive experience. The ultimate goal of home ventilator therapy is to enhance the patient’s quality of life, not simply to support or prolong life.
Unit 5
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GAS EXCHANGE AND RESPIRATORY FUNCTION
Chart 25-14 Home Care Checklist • Ventilator Care At the completion of the home care instruction, the patient or caregiver will be able to: • State proper care of patient on ventilator Observe physical signs such as color, secretions, breathing pattern, and state of consciousness. Perform physical care such as suctioning, postural drainage, and ambulation. Observe the tidal volume and pressure manometer regularly. Intervene when they are abnormal (ie, suction if airway pressure increases). Provide a communication method for the patient (eg, pad and pencil, electric larynx, talking tracheostomy). Monitor vital signs as directed. Indicate when feeling short of breath or in distress by a predetermined signal. • Care for and maintain equipment properly Check the ventilator settings twice each day and whenever the patient is removed from the ventilator. Adjust the volume and pressure alarms if needed. Fill humidifier as needed and check its level three times a day. Empty water in tubing as needed. Use a clean humidifier when circuitry is changed. Keep exterior of ventilator clean and free of any objects. Change external circuitry once a week or more often as indicated. Report malfunction or strange noises immediately
NURSING PROCESS: THE PATIENT ON A VENTILATOR Assessment The nurse has a vital role in assessing the patient’s status and the functioning of the ventilator. In assessing the patient, the nurse evaluates the patient’s physiologic status and how he or she is coping with mechanical ventilation. Physical assessment includes systematic assessment of all body systems, with an in-depth focus on the respiratory system. Respiratory assessment includes vital signs, respiratory rate and pattern, breath sounds, evaluation of spontaneous ventilatory effort, and potential evidence of hypoxia. Increased adventitious breath sounds may indicate a need for suctioning. The nurse also evaluates the settings and functioning of the mechanical ventilator, as described previously. Assessment also addresses the patient’s neurologic status and effectiveness of coping with the need for assisted ventilation and the changes that accompany it. The nurse should assess the patient’s comfort level and ability to communicate as well. Finally, weaning from mechanical ventilation requires adequate nutrition. Therefore, it is important to assess the function of the gastrointestinal system and nutritional status.
Diagnosis NURSING DIAGNOSES Based on the assessment data, the patient’s major nursing diagnoses may include:
• Impaired gas exchange related to underlying illness, or ventilator setting adjustment during stabilization or weaning.
• Ineffective airway clearance related to increased mucus pro• •
duction associated with continuous positive-pressure mechanical ventilation Risk for trauma and infection related to endotracheal intubation or tracheostomy Impaired physical mobility related to ventilator dependency
Patient
Caregiver
✓ ✓
✓
✓
✓
✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓
• Impaired verbal communication related to endotracheal tube and attachment to ventilator
• Defensive coping and powerlessness related to ventilator dependency COLLABORATIVE PROBLEMS/ POTENTIAL COMPLICATIONS Based on assessment data, potential complications may include:
• • • •
Alterations in cardiac function Barotrauma (trauma to the alveoli) and pneumothorax Pulmonary infection Sepsis
Planning and Goals The major goals for the patient may include achievement of optimal gas exchange, maintenance of a patent airway, absence of trauma or infection, attainment of optimal mobility, adjustment to nonverbal methods of communication, acquisition of successful coping measures, and absence of complications.
Nursing Interventions Nursing care of the mechanically ventilated patient requires expert technical and interpersonal skills. Nursing interventions are similar regardless of the setting; however, the frequency of interventions and the stability of the patient vary from setting to setting. Nursing interventions for the mechanically ventilated patient are not uniquely different from other pulmonary patients, but astute nursing assessment and a therapeutic nurse–patient relationship are critical. The specific interventions used by the nurse are determined by the underlying disease process and the patient’s response. Two general nursing interventions important in the care of the mechanically ventilated patient are pulmonary auscultation and interpretation of arterial blood gas measurements. The nurse is often the first to note changes in physical assessment findings or significant trends in blood gases that signal the development of a
Chapter 25 serious problem (eg, pneumothorax, tube displacement, pulmonary embolus). ENHANCING GAS EXCHANGE The purpose of mechanical ventilation is to optimize gas exchange by maintaining alveolar ventilation and oxygen delivery. The alteration in gas exchange may be due to the underlying illness or to mechanical factors related to the adjustment of the machine to the patient. The health care team, including the nurse, physician, and respiratory therapist, continually assesses the patient for adequate gas exchange, signs and symptoms of hypoxia, and response to treatment. Thus, the nursing diagnosis impaired gas exchange is, by its complex nature, multidisciplinary and collaborative. The team members must share goals and information freely. All other goals directly or indirectly relate to this primary goal. Nursing interventions to promote optimal gas exchange include judicious administration of analgesic agents to relieve pain without suppressing the respiratory drive and frequent repositioning to diminish the pulmonary effects of immobility. The nurse also monitors for adequate fluid balance by assessing for the presence of peripheral edema, calculating daily intake and output, and monitoring daily weights. The nurse administers medications prescribed to control the primary disease and monitors for their side effects. PROMOTING EFFECTIVE AIRWAY CLEARANCE Continuous positive-pressure ventilation increases the production of secretions regardless of the patient’s underlying condition. The nurse assesses for the presence of secretions by lung auscultation at least every 2 to 4 hours. Measures to clear the airway of secretions include suctioning, chest physiotherapy, frequent position changes, and increased mobility as soon as possible. Frequency of suctioning should be determined by patient assessment. If excessive secretions are identified by inspection or auscultation techniques, suctioning should be performed. Sputum is not produced continuously or every 1 to 2 hours but as a response to a pathologic condition. Therefore, there is no rationale for routine suctioning of all patients every 1 to 2 hours. Although suctioning is used to aid in the clearance of secretions, it can damage the airway mucosa and impair cilia action (Scanlan, Wilkins & Stoller, 1999). The sigh mechanism on the ventilator may be adjusted to deliver at least one to three sighs per hour at 1.5 times the tidal volume if the patient is on assist–control. Because of the risk of hyperventilation and trauma to pulmonary tissue from excess ventilator pressure (barotrauma, pneumothorax), this feature is not being used as frequently today. If the patient is on the synchronized intermittent mandatory ventilation (SIMV) mode, the mandatory ventilations act as sighs because they are of greater volume than the patient’s spontaneous breaths. Periodic sighing prevents atelectasis and the further retention of secretions. Humidification of the airway via the ventilator is maintained to help liquefy secretions so they are more easily removed. Bronchodilators are administered to dilate the bronchioles and are classified as adrenergic or anticholinergic. Adrenergic bronchodilators are mostly inhaled and work by stimulating the betareceptor sites, mimicking the effects of epinephrine in the body. The desired effect is smooth muscle relaxation, thus dilating the constricted bronchial tubes. Medications include albuterol (Proventil, Ventolin), isoetharine (Bronkosol), isoproterenol (Isuprel), metaproterenol (Alupent, Metaprel), pirbuterol acetate (Maxair), salmeterol (Serevent), and terbutaline (Brethine, Brethaire, Bricanyl). Tachycardia, heart palpitations, and tremors are side effects that have been reported with use of these medications (Zang & Allender, 1999). Anticholinergic bronchodilators
Respiratory Care Modalities
621
such as ipratropium (Atrovent) and ipratropium with albuterol (Combivent) produce airway relaxation by blocking cholinergicinduced bronchoconstriction. Patients receiving bronchodilator therapy of either type should be monitored for adverse effects including dizziness, nausea, decreased oxygen saturation, hypokalemia, increased heart rate, and urine retention. Mucolytic agents such as acetylcysteine (Mucomyst) are administered as prescribed to liquefy secretions so that they are more easily mobilized. Nursing management of patients receiving mucolytic therapy includes assessment for an adequate cough reflex, sputum characteristics, and improvement in incentive spirometry (McKenry & Salerno, 2001). Side effects include nausea, vomiting, bronchospasm, stomatitis (oral ulcers), urticaria, and runny nose (LeFever & Hayes, 2000). PREVENTING TRAUMA AND INFECTION Airway management must involve maintaining the endotracheal or tracheostomy tube. The nurse positions the ventilator tubing so that there is minimal pulling or distortion of the tube in the trachea; this reduces the risk of trauma to the trachea. Cuff pressure is monitored every 8 hours to maintain the pressure at less than 25 cm H2O. The nurse evaluates for the presence of a cuff leak at the same time. Patients with endotracheal intubation or a tracheostomy tube do not have the normal defenses of the upper airway. In addition, these patients frequently have multiple additional body system disturbances that lead to immunocompromise. Tracheostomy care is performed at least every 8 hours, and more frequently if needed, because of the increased risk of infection. The ventilator circuit and in-line suction tubing is replaced periodically, according to infection control guidelines, to decrease the risk of infection. The nurse administers oral hygiene frequently because the oral cavity is a primary source of contamination of the lungs in the intubated and compromised patient. The presence of a nasogastric tube in the intubated patient can increase the risk for aspiration, leading to nosocomial pneumonia. The nurse positions the patient with the head elevated above the stomach as much as possible. Antiulcer medications such as sucralfate (Carafate) are given to maintain normal gastric pH; research has demonstrated a lower incidence of aspiration pneumonia when sucralfate is administered (Scanlan, Wilkins & Stoller, 1999). PROMOTING OPTIMAL LEVEL OF MOBILITY The patient’s mobility is limited because he or she is connected to the ventilator. The nurse should assist a patient whose condition has become stable to get out of bed and to a chair as soon as possible. Mobility and muscle activity are beneficial because they stimulate respirations and improve morale. If the patient cannot get out of bed, the nurse encourages the patient to perform active range-of-motion exercises every 6 to 8 hours. If the patient cannot perform these exercises, the nurse performs passive range-ofmotion exercises every 8 hours to prevent contractures and venous stasis. PROMOTING OPTIMAL COMMUNICATION It is important to develop alternative methods of communication for the patient on a ventilator. The nurse assesses the patient’s communication abilities to evaluate for limitations. Questions to consider when assessing the ventilator-dependent patient’s ability to communicate include the following:
• Is the patient conscious and able to communicate? Can the patient nod or shake the head?
622
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• Is the patient’s mouth unobstructed by the tube so that •
words can be mouthed? Is the patient’s hand strong and available for writing? (For example, if the patient is right-handed, the intravenous line is placed in the left arm if possible so that the right hand is free.)
Once the patient’s limitations are known, the nurse offers several appropriate communication approaches: lip reading (use single key words), pad and pencil or Magic Slate, communication board, gesturing, or electric larynx. Use of a “talking” or fenestrated tracheostomy tube may be suggested to the physician; this allows the patient to talk while on the ventilator. If indicated, the nurse should make sure that the patient’s eyeglasses and hearing aid and a translator are available to enhance the patient’s ability to communicate. The patient must be assisted to find the most suitable communication method. Some methods may be frustrating to the patient, family, and nurse; these need to be identified and minimized. A speech therapist can assist in determining the most appropriate method. PROMOTING COPING ABILITY Dependence on a ventilator is frightening to both the patient and family and disrupts even the most stable families. Encouraging the family to verbalize their feelings about the ventilator, the patient’s condition, and the environment in general is beneficial. Explaining procedures every time they are performed helps to reduce anxiety and familiarizes the patient with ventilator procedures. To restore a sense of control, the nurse encourages the patient to participate in decisions about care, schedules, and treatment when possible. The patient may become withdrawn or depressed while on mechanical ventilation, especially if its use is prolonged. To promote effective coping, the nurse informs the patient about progress when appropriate. It is important to provide diversions such as watching television, playing music, or taking a walk (if appropriate and possible). Stress reduction techniques (eg, a backrub, relaxation measures) help relieve tension and help the patient to deal with anxieties and fears about both the condition and the dependence on the ventilator. MONITORING AND MANAGING POTENTIAL COMPLICATIONS Alterations in Cardiac Function Alterations in cardiac output may occur as a result of positivepressure ventilation. The positive intrathoracic pressure during inspiration compresses the heart and great vessels, thereby reducing venous return and cardiac output. This is usually corrected during exhalation when the positive pressure is off. Patients may have decreased cardiac output and resultant decreased tissue perfusion and oxygenation. To evaluate cardiac function, the nurse first looks for signs and symptoms of hypoxia (restlessness, apprehension, confusion, tachycardia, tachypnea, labored breathing, pallor progressing to cyanosis, diaphoresis, transient hypertension, and decreased urine output). If a pulmonary artery catheter is in place, cardiac output, cardiac index, and other hemodynamic values can be used to assess the patient’s status. Barotrauma and Pneumothorax Excessive positive pressure may cause barotrauma, which results in a spontaneous pneumothorax. This may quickly develop into a tension pneumothorax, further compromising venous return,
cardiac output, and blood pressure. The nurse should consider any sudden onset of changes in oxygen saturation or respiratory distress to be a life-threatening emergency requiring immediate action. Pulmonary Infection The patient is at high risk for infection, as described above. The nurse should report fever or a change in the color or odor of sputum to the physician for follow-up.
Evaluation EXPECTED PATIENT OUTCOMES Expected patient outcomes may include: 1. Exhibits adequate gas exchange, as evidenced by normal breath sounds, acceptable arterial blood gas levels, and vital signs 2. Demonstrates adequate ventilation with minimal mucus accumulation 3. Is free of injury or infection, as evidenced by normal temperature and white blood count 4. Is mobile within limits of ability a. Gets out of bed to chair, bears weight, or ambulates as soon as possible b. Performs range-of-motion exercises every 6 to 8 hours 5. Communicates effectively through written messages, gestures, or other communication strategies 6. Copes effectively a. Verbalizes fears and concerns about condition and equipment b. Participates in decision making when possible c. Uses stress reduction techniques when necessary 7. Absence of complications a. Absence of cardiac compromise, as evidenced by stable vital signs and adequate urine output b. Absence of pneumothorax, as evidenced by bilateral chest excursion, normal chest x-ray, and adequate oxygenation c. Absence of pulmonary infection, as evidenced by normal temperature, clear pulmonary secretions, and negative sputum cultures
WEANING THE PATIENT FROM THE VENTILATOR Respiratory weaning, the process of withdrawing the patient from dependence on the ventilator, takes place in three stages: the patient is gradually removed from the ventilator, then from the tube, and finally from oxygen. Weaning from mechanical ventilation is performed at the earliest possible time consistent with patient safety. The decision must be made from a physiologic rather than from a mechanical viewpoint. A thorough understanding of the patient’s clinical status is required in making this decision. Weaning is started when the patient is recovering from the acute stage of medical and surgical problems and when the cause of respiratory failure is sufficiently reversed. Successful weaning involves collaboration among the physician, respiratory therapist, and nurse. Each health care provider must understand the scope and function of other team members in relation to patient weaning to conserve the patient’s strength, use resources efficiently, and maximize successful outcomes.
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NURSING RESEARCH PROFILE 25-2
Early Versus Late Tracheostomy Decannulation Clini, E., Vitacca, M., Bianchi, L., Porta, R., & Ambrosino, N. (1999). Long-term tracheostomy in severe COPD patients weaned from mechanical ventilation. Respiratory Care, 44(4), 241–244.
Purpose Patients with chronic obstructive pulmonary disease (COPD) who require mechanical ventilation for management of acute respiratory failure are at risk for relapse. It is not known if patients with spontaneous respirations would benefit from retaining a tracheostomy after discharge from the intensive care unit. This study was conducted to determine the effects of maintaining a tracheal cannula in spontaneously breathing patients following discharge. Study Sample and Design Investigators studied 20 patients with severe COPD who were undergoing weaning from mechanical ventilation. The researchers used a prospective, randomized, and controlled design to measure tracheal cannula use in two groups of patients: 10 patients had the tracheal cannula removed, and 10 did not. Breathing pattern, forced lung volumes, respiratory muscle strength, and arterial blood gases were evaluated in patients at hospital discharge and at 1, 3, and 6 months after discharge. Investigators measured breathing patterns and forced lung volumes with a portable spirometer and assessed respiratory muscle strength by measuring maximal inspiratory pressure. They also recorded number
Criteria for Weaning Careful assessment is required to determine whether the patient is ready to be removed from mechanical ventilation. If the patient is stable and showing signs of improvement or reversal of the disease or condition that caused the need for mechanical ventilation, weaning indices should be assessed. These indices include:
• Vital capacity: the amount of air expired after maximum in-
• • • •
spiration. Used to assess the patient’s ability to take deep breaths. Vital capacity should be 10 to 15 mL/kg to meet the criteria for weaning. Maximum inspiratory pressure (MIP): used to assess the patient’s respiratory muscle strength. It is also known as negative inspiratory pressure and should be at least −20 cm H2O. Tidal volume: volume of air that is inhaled or exhaled from the lungs during an effortless breath. It is normally 7 to 9 mL/kg. Minute ventilation: equal to the respiratory rate multiplied by tidal volume. Normal is about 6 L/min. Rapid/shallow breathing index: used to assess the breathing pattern and is calculated by dividing the respiratory rate by tidal volume. Patients with indices below 100 breaths/min/L are more likely to be successful at weaning.
Other measurements used to assess readiness for weaning include a PaO2 of greater than 60 mm Hg with an FiO2 of less than 40%. Stable vital signs and arterial blood gases are also important predictors of successful weaning. Once readiness has been determined, the nurse records baseline measurements of weaning indices to monitor progress (Cull & Inwood, 1999).
Patient Preparation To maximize the chances of success of weaning, the nurse must consider the patient as a whole, taking into account factors that impair the delivery of oxygen and elimination of carbon dioxide
of hospital days, mortality rate, and number of new exacerbations requiring antibiotics. Results No significant differences were found between the two groups with regard to breathing patterns, forced lung volumes, respiratory strength, or arterial blood gases. In both groups, 2 of the 10 patients (20%) died due to respiratory causes. During the follow-up period, exacerbations were significantly greater in the patients with tracheostomies than in those whose tracheostomies had been removed (p < .005). Nursing Implications The findings of this study suggest that retaining a chronic tracheostomy following weaning from mechanical ventilation in patients with COPD is associated with a higher frequency of adverse events, including exacerbations requiring treatment with antibiotics. Although there were no significant findings with regard to breathing pattern, forced lung volumes, respiratory muscle strength, and arterial blood gases, the patient population was small, thus necessitating further study. The results suggest that clinics should consider early decannulation in COPD patients weaned from mechanical ventilation.
as well as those that increase oxygen demand (sepsis, seizures, thyroid imbalances) or decrease the patient’s overall strength (nutrition, neuromuscular disease). Adequate psychological preparation is necessary before and during the weaning process. Patients need to know what is expected of them during the procedure. They are often frightened by having to breathe on their own again and need reassurance that they are improving and are well enough to handle spontaneous breathing. The nurse explains what will happen during weaning and what role the patient will play in the procedure. The nurse emphasizes that someone will be with or near the patient at all times, and answers any questions simply and concisely. Proper preparation of the patient can reduce the weaning time.
Methods of Weaning Considerable effort has been devoted to finding the best method of weaning from mechanical ventilation, but research has not established which method is best (Tasota & Dobbin, 2000). Success depends on the combination of adequate patient preparation, available equipment, and an interdisciplinary approach to solving patient problems (Chart 25-15). The most common weaning methods in use today are described below. Assist–control may be used as the resting mode for patients undergoing weaning trials. This mode provides full ventilatory support by delivering a preset tidal volume and respiratory rate; if the patient takes a breath, the ventilator delivers the preset volume. The cycle does not adapt to the patient’s spontaneous efforts. The nurse assesses patients being weaned on this mode for the following signs of distress: rapid shallow breathing, use of accessory muscles, reduced level of consciousness, increase in carbon dioxide levels, decrease in oxygen saturations, and tachycardia. The patient on intermittent mandatory ventilation (IMV) can increase the respiratory rate, but each spontaneous breath receives only the tidal volume the patient generates. Mechanical breaths
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Chart 25-15 GUIDELINES FOR Care of the Patient Being Weaned From Mechanical Ventilation NURSING INTERVENTIONS
RATIONALE
1. Assess patient for weaning criteria: Vital capacity—10 to 15 mL/kg Maximum inspiratory pressure (MIP) at least –20 cm H2O Tidal volume—7 to 9 mL/kg Minute ventilation—6 L/min Rapid/shallow breathing index—below 100 breaths/minute/L PaO2 greater than 60 mm Hg with FiO2 less than 40% 2. Monitor activity level, assess dietary intake, and monitor results of laboratory tests of nutritional status.
1. Careful assessment of multiple weaning indices helps to determine readiness for weaning. When the criteria have been met, the patient’s likelihood of successful weaning increases.
3. Assess the patient’s and family’s understanding of the weaning process and address any concerns about the process. Explain that the patient may feel short of breath initially and provide encouragement as needed. Reassure the patient that he or she will be attended closely and that if the weaning attempt is not successful, it can be tried again later. 4. Implement the weaning method prescribed: A/C, IMV, SIMV, PSV, PAV, CPAP, or T-piece. 5. Monitor vital signs, pulse oximetry, ECG, and respiratory pattern constantly for the first 20 to 30 minutes and every 5 minutes after that until weaning is complete. 6. Maintain a patent airway; monitor arterial blood gas levels and pulmonary function tests. Suction the airway as needed. 7. In collaboration with the physician, terminate the weaning process if adverse reactions occur. These include a heart rate increase of 20 beats/min, systolic blood pressure increase of 20 mm Hg, a decrease in oxygen saturation to less than 90%, respiratory rate less than 8 or greater than 20 breaths/minute, ventricular dysrhythmias, fatigue, panic, cyanosis, erratic or labored breathing, paradoxical chest movement. 8. If the weaning process continues, measure tidal volume and minute ventilation every 20 to 30 minutes; compare with the patient’s desired values, which have been determined in collaboration with the physician. 9. Assess for psychological dependence if the physiologic parameters indicate weaning is feasible and the patient still resists.
are delivered at preset intervals and a preselected tidal volume, regardless of the patient’s efforts. IMV allows patients to use their own muscles of ventilation to help prevent muscle atrophy. IMV lowers mean airway pressure, which can assist in preventing barotrauma. Synchronized intermittent mandatory ventilation (SIMV) delivers a preset tidal volume and number of breaths per minute. Between ventilator-delivered breaths, the patient can breathe spontaneously with no assistance from the ventilator on those extra breaths. As the patient’s ability to breathe spontaneously increases, the preset number of ventilator breaths is decreased and the patient does more of the work of breathing. SIMV is indicated if the patient satisfies all the criteria for weaning but cannot sustain adequate spontaneous ventilation for long periods. IMV and SIMV can be used to provide full or partial ventilatory support. Nursing interventions for both of these include
2. Reestablishing independent spontaneous ventilation can be physically exhausting. It is crucial that the patient have enough energy reserves to succeed. Providing periods of rest and recommended nutritional intake can increase the likelihood of successful weaning. 3. The weaning process can be psychologically tiring; emotional support can help promote a sense of security. Explaining that weaning will be attempted again later helps reduce the sense of failure if the first attempts are unsuccessful. 4. The prescribed weaning method should reflect the patient’s individualized criteria for weaning and weaning history. By having different methods to choose from, the physician can select the one that best fits the patient. 5. Monitoring the patient closely provides ongoing indications of success or failure. 6. These values can be compared to baseline measurements to evaluate weaning. Suctioning helps to reduce the risk of aspiration and maintain the airway. 7. These signs and symptoms indicate an unstable patient at risk for hypoxia and ventricular dysrhythmias. Continuing the weaning process can lead to cardiopulmonary arrest.
8. These values help to determine if weaning is successful and should be continued. 9. Psychological dependence is a common problem after mechanical ventilation. Possible causes include fear of dying and depression from chronic illness. It is important to address this issue before the next weaning attempt.
monitoring progress by recording respiratory rate, minute volume, spontaneous and machine-generated tidal volume, FiO2, and arterial blood gas levels. The pressure support ventilation (PSV) mode assists SIMV by applying a pressure plateau to the airway throughout the patienttriggered inspiration to decrease resistance by the tracheal tube and ventilator tubing. Pressure support is reduced gradually as the patient’s strength increases. A SIMV backup rate may be added for extra support. The nurse must closely observe the patient’s respiratory rate and tidal volumes on initiation of PSV. It may be necessary to adjust the pressure support to avoid tachypnea or large tidal volumes. The proportional assist ventilation (PAV) mode of partial ventilatory support allows the ventilator to generate pressure in proportion to the patient’s efforts. With every breath, the ventilator synchronizes with the patient’s ventilatory efforts (Giannouli,
Chapter 25 Webster, Roberts & Younes, 1999). Nursing assessment should include careful monitoring of the patient’s respiratory rate, arterial blood gases, tidal volume, minute ventilation, and breathing pattern. The continuous positive airway pressure (CPAP) mode allows the patient to breathe spontaneously, while applying positive pressure throughout the respiratory cycle to keep the alveoli open and promote oxygenation. Providing CPAP during spontaneous breathing also offers the advantage of an alarm system and may reduce patient anxiety if the patient has been taught that the machine is keeping track of breathing. It also maintains lung volumes and improves the patient’s oxygenation status. CPAP is often used in conjunction with PSV. Nurses should carefully assess for tachypnea, tachycardia, reduced tidal volumes, decreasing oxygen saturations, and increasing carbon dioxide levels. Weaning trials using a T-piece or tracheostomy mask (see Fig. 25-2) are normally conducted with the patient disconnected from the ventilator, receiving humidified oxygen only, and performing all work of breathing. Patients who do not have to overcome the resistance of the ventilator may find this mode more comfortable, or they may become anxious as they breathe with no support from the ventilator. During T-piece trials, the nurse monitors the patient closely and provides encouragement. This method of weaning is usually used when the patient is awake and alert, is breathing without difficulty, has good gag and cough reflexes, and is hemodynamically stable. During the weaning process, the patient is maintained on the same or a higher oxygen concentration than when on the ventilator. While on the T-piece, the patient should be observed for signs and symptoms of hypoxia, increasing respiratory muscle fatigue, or systemic fatigue. These include restlessness, increased respiratory rate greater than 35 breaths/min, use of accessory muscles, tachycardia with premature ventricular contractions, and paradoxical chest movement (asynchronous breathing, chest contraction during inspiration and expansion during expiration). Fatigue or exhaustion is initially manifested by an increased respiratory rate associated with a gradual reduction in tidal volume; later there is a slowing of the respiratory rate. If the patient appears to be tolerating the T-piece trial, a second set of arterial blood gas measurements is drawn 20 minutes after the patient has been on spontaneous ventilation at a constant FiO2 pressure support ventilation. (Alveolar–arterial equilibration takes 15 to 20 minutes to occur.) Signs of exhaustion and hypoxia correlated with deterioration in the blood gas measurements indicate the need for ventilatory support. The patient is placed back on the ventilator each time signs of fatigue or deterioration develop. If clinically stable, the patient usually can be extubated within 2 or 3 hours of weaning and allowed spontaneous ventilation by means of a mask with humidified oxygen. Patients who have had prolonged ventilatory assistance usually require more gradual weaning; it may take days or even weeks. They are weaned primarily during the day and placed back on the ventilator at night to rest. Because patients respond in different manners to the various weaning methods, there is no definitive way to assess which method is best. With all of the methods, ongoing assessment of respiratory status is essential to monitor patient progress (Woodruff, 1999). Successful weaning from the ventilator is supplemented by intensive pulmonary care. The following are continued:
• Oxygen therapy • Arterial blood gas evaluation
• • • • •
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Pulse oximetry Bronchodilator therapy Chest physiotherapy Adequate nutrition, hydration, and humidification Incentive spirometry
These patients still have borderline pulmonary function and need vigorous supportive therapy before their respiratory status returns to a level that supports activities of daily living.
Weaning From the Tube Weaning from the tube is considered when the patient can breathe spontaneously, maintain an adequate airway by effectively coughing up secretions, swallow, and move the jaw. If frequent suctioning is needed to clear secretions, tube weaning may be unsuccessful (Ecklund, 1999). Secretion clearance and aspiration risks are assessed to determine if active pharyngeal and laryngeal reflexes are intact. Once the patient can clear secretions adequately, a trial period of mouth breathing or nose breathing is conducted. This can be accomplished by several methods. The first method requires changing to a smaller size tube to increase the resistance to airflow and simultaneously plugging the tracheostomy tube (deflating the cuff ). The smaller tube is sometimes replaced by a cuffless tracheostomy tube, which allows the tube to be plugged at lengthening intervals to monitor patient progress. A second method involves changing to a fenestrated tube (a tube with an opening or window in its bend). This permits air to flow around and through the tube to the upper airway and enables talking. A third method involves switching to a smaller tracheostomy button (stoma button). A tracheostomy button is a plastic tube approximately 1 inch long that helps to keep the windpipe open after the larger tracheostomy tube has been removed. Finally, when the patient demonstrates the ability to maintain a patent airway without a tracheostomy tube, the tube can be removed. An occlusive dressing is placed over the stoma, which usually heals anywhere from several days to many weeks (Ecklund, 1999).
Weaning From Oxygen The patient who has been successfully weaned from the ventilator, cuff, and tube and has adequate respiratory function is then weaned from oxygen. The FiO2 is gradually reduced until the PaO2 is in the range of 70 to 100 mm Hg while the patient is breathing room air. If the PaO2 is less than 70 mm Hg on room air, supplemental oxygen is recommended. The Centers for Medicare and Medicaid Services, formerly the Health Care Financing Administration (HCFA), requires that the patient’s PaO2 on room air be less than 55 mm Hg for the patient to be eligible for financial reimbursement for in-home oxygen.
Nutrition Success in weaning the long-term ventilator-dependent patient requires early and aggressive but judicious nutritional support. The respiratory muscles (diaphragm and especially intercostals) become weak or atrophied after just a few days of mechanical ventilation, especially if nutrition is inadequate. Fat kilocalories produce less carbon dioxide than carbohydrate kilocalories. For this reason, a high-fat diet may assist patients with respiratory failure who are being weaned from mechanical ventilation. Research is being conducted on the role of fatty acids in lung disease (Schwartz,
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2000). A high-fat diet may provide as much as 50% of the total daily kilocalories. Adequate protein intake is important in increasing respiratory muscle strength. Protein intake should be approximately 25% of total daily kilocalories, or 1.2 to 1.5 g/kg/day. Because a high-carbohydrate diet can lead to increased carbon dioxide production and retention, total carbohydrate intake should not exceed 25% of total daily kilocalories, or 2 g/kg/day in patients being weaned from mechanical ventilation. Care must be taken not to overfeed patients because excessive intake can raise the demand for oxygen and the production of carbon dioxide. Total daily kilocalories should be closely monitored (Lutz & Prytulski, 2001). Soon after the patient is admitted, a consultation with a dietitian or nutrition support team should be arranged to plan the best form of nutritional replacement. Adequate nutrition may decrease the duration of mechanical ventilation and prevent other complications, especially sepsis. Sepsis can occur if bacteria enter the bloodstream and release toxins that, in turn, cause vasodilation and hypotension, fever, tachycardia, increased respiratory rate, and coma. Aggressive treatment of sepsis is essential to reverse this threat to survival and to promote weaning from the ventilator when the patient’s condition improves. Optimal nutritional intake is an essential part of the treatment of sepsis.
The Patient Undergoing Thoracic Surgery Assessment and management are particularly important in the patient undergoing thoracic surgery. Frequently, patients undergoing such surgery also have obstructive pulmonary disease with compromised breathing. Preoperative preparation and careful postoperative management are crucial for successful patient outcomes because these patients may have a narrow range between their physical tolerance for certain activities and their limitations, which, if exceeded, can lead to distress. Various types of thoracic surgical procedures are performed to relieve disease conditions such as lung abscesses, lung cancer, cysts, and benign tumors (Chart 25-16). An exploratory thoracotomy (creation of a surgical opening into the thoracic cavity) may be performed to diagnose lung or chest disease. A biopsy may be performed in this procedure with a small amount of lung tissue removed for analysis; the chest incision is then closed. The objectives of preoperative care for the patient undergoing thoracic surgery are to ascertain the patient’s functional reserve to determine if the patient can survive the surgery and to ensure that the patient is in optimal condition for surgery.
The patient history and assessment should include the following questions:
• What signs and symptoms are present (cough, sputum ex• • • • • •
pectorated [amount and color], hemoptysis, chest pain, dyspnea)? If there is a smoking history, how long has the patient smoked? Does the patient smoke currently? How many packs a day? What is the patient’s cardiopulmonary tolerance while resting, eating, bathing, and walking? What is the patient’s breathing pattern? How much exertion is required to produce dyspnea? Does the patient need to sleep in an upright position or with more than two pillows? What is the patient’s physiologic status (eg, general appearance, mental alertness, behavior, nutritional status)? What other medical conditions exist (eg, allergies, cardiac disorders, diabetes)?
A number of tests are performed to determine the patient’s preoperative status and to assess the patient’s physical assets and limitations. Many patients are seen by their surgeons in the office, and many tests and examinations are performed on an outpatient basis. The decision to perform any pulmonary resection is based on the patient’s cardiovascular status and pulmonary reserve. Pulmonary function studies (especially lung volume and vital capacity) are performed to determine whether the planned resection will leave sufficient functioning lung tissue. Arterial blood gas values are assessed to provide a more complete picture of the functional capacity of the lung. Exercise tolerance tests are useful to determine if the patient who is a candidate for pneumonectomy can tolerate removal of one of the lungs. Preoperative studies are performed to provide a baseline for comparison during the postoperative period and to detect any unsuspected abnormalities. These studies may include a bronchoscopic examination (a lighted scope is inserted into the airways to examine the bronchi), chest x-ray, electrocardiogram (for arteriosclerotic heart disease, conduction defects), nutritional assessment, determination of blood urea nitrogen and serum creatinine (renal function), glucose tolerance or blood glucose (diabetes), assessment of serum electrolytes and protein levels, blood volume determinations, and complete blood cell count.
PREOPERATIVE NURSING MANAGEMENT PREOPERATIVE MANAGEMENT Assessment and Diagnostic Findings The nurse performs chest auscultation to assess breath sounds in the different regions of the lungs (see Chap. 21). It is important to note if breath sounds are normal, indicating a free flow of air in and out of the lungs. (In the patient with emphysema, the breath sounds may be markedly decreased or even absent on auscultation.) The nurse notes crackles and wheezes and assesses for hyperresonance and decreased diaphragmatic motion. Unilateral diminished breath sounds and rhonchi can be the result of occlusion of the bronchi by mucus plugs. The nurse assesses for retained secretions during auscultation by asking the patient to cough. It is important to note any signs of rhonchi or wheezing.
Improving Airway Clearance The underlying lung condition often is associated with increased respiratory secretions. Before surgery, the airway is cleared of secretions to reduce the possibility of postoperative atelectasis or infection. Risk factors for postoperative atelectasis and pneumonia are listed in Chart 25-17. Strategies to reduce the risk for atelectasis and infection include humidification, postural drainage, and chest percussion after bronchodilators are administered, if prescribed. The nurse estimates the volume of sputum if the patient expectorates large amounts of secretions. Such measurements are carried out to determine if and when the amount decreases. Antibiotics are administered as prescribed for infection, which may be causing the excessive secretions.
Chapter 25
Chart 25-16
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Thoracic Surgeries and Procedures
Pneumonectomy The removal of an entire lung (pneumonectomy) is performed chiefly for cancer when the lesion cannot be removed by a less extensive procedure. It also may be performed for lung abscesses, bronchiectasis, or extensive unilateral tuberculosis. The removal of the right lung is more dangerous than the removal of the left, because the right lung has a larger vascular bed and its removal imposes a greater physiologic burden. A posterolateral or anterolateral thoracotomy incision is made, sometimes with resection of a rib. The pulmonary artery and the pulmonary veins are ligated and severed. The main bronchus is divided and the lung removed. The bronchial stump is stapled, and usually no drains are used because the accumulation of fluid in the empty hemithorax prevents mediastinal shift.
Overinflated left lung Fluid filled thoracic cavity Stump of right main bronchus Elevated diaphragm Mediastinum shifted to right
Pneumonectomy
Lobectomy When the pathology is limited to one area of a lung, a lobectomy (removal of a lobe of a lung) is performed. Lobectomy, which is more common than pneumonectomy, may be carried out for bronchogenic carcinoma, giant emphysematous blebs or bullae, benign tumors, metastatic malignant tumors, bronchiectasis, and fungus infections.
Segmentectomy (Segmental Resection) Some lesions are located in only one segment of the lung. Bronchopulmonary segments are subdivisions of the lung that function as individual units. They are held together by delicate connective tissue. Disease processes may be limited to a single segment. Care is used to preserve as much healthy and functional lung tissue as possible, especially in patients who already have limited cardiopulmonary reserve. Single segments can be removed from any lobe; the right middle lobe, which has only two small segments, invariably is removed entirely. On the left side, corresponding to a middle lobe, is a “lingular” segment of the upper lobe. This can be removed as a single segment or by lingulectomy. This segment frequently is involved in bronchiectasis. Wedge Resection A wedge resection of a small, well-circumscribed lesion may be performed without regard for the location of the intersegmental planes. The pleural cavity usually is drained because of the possibility of an air or blood leak. This procedure is performed for diagnostic lung biopsy and for the excision of small peripheral nodules. Bronchoplastic or Sleeve Resection Bronchoplastic resection is a procedure in which only one lobar bronchus, together with a part of the right or left bronchus, is excised. The distal bronchus is reanastomosed to the proximal bronchus or trachea. Lung Volume Reduction Lung volume reduction is a surgical procedure involving the removal of 20% to 30% of a patient’s lung through a midsternal incision or video thoracoscopy. The diseased lung tissue is identified on a lung perfusion scan. Although some patients with chronic obstructive pulmonary disease have reported an improvement in the quality of their lives for at least 6 months to 1 year after the surgery, results have generally been disappointing. Research is ongoing to examine the benefits of lung volume reduction surgery using video thoracoscopy (Baker & Flynn, 1999; National Institutes of Health, 2001). Video Thoracoscopy A video thoracoscopy is an endoscopic procedure that allows the surgeon to look into the thorax without making a large incision. The procedure is performed to obtain specimens of tissue for biopsy, to treat recurrent spontaneous pneumothorax, and to diagnose either pleural effusions or pleural masses. Thoracoscopy has also been found to be an effective diagnostic and therapeutic alternative for the treatment of mediastinal disorders (Cirino et al., 2000). Some advantages of video thoracoscopy include rapid diagnosis and treatment of some conditions, a decrease in postoperative complications, and a shortened hospital stay (see Chap. 21).
Stump of upper lobe Overinflated middle lobe Overinflated lower lobe Elevation of diaphragm Mediastinum shifted to right
Lobectomy
The surgeon makes a thoracotomy incision: its exact location depends on the lobe to be resected. When the pleural space is entered, the involved lung collapses and the lobar vessels and the bronchus are ligated and divided. After the lobe is removed, the remaining lobes of the lung are reexpanded. Usually, two chest catheters are inserted for drainage. The upper tube is for air removal; the lower one is for fluid drainage. Sometimes, only one catheter is needed. The chest tube is connected to a chest drainage apparatus for several days.
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Chart 25-17
Risk Factors for Surgery-Related Atelectasis and Pneumonia Preoperative Risk Factors Increased age Obesity Poor nutritional status Smoking history Abnormal pulmonary function tests Preexisting lung disease Emergency surgery History of aspiration Comorbid states Preexisting disability Intraoperative Risk Factors Thoracic incision Prolonged anesthesia Postoperative Risk Factors Immobilization Supine position Decreased level of consciousness Inadequate pain management Prolonged intubation/mechanical ventilation Presence of nasogastric tube Inadequate preoperative education
Teaching the Patient Increasingly, patients are admitted on the day of surgery, which does not provide much time for the acute care nurse to talk with the patient. Nurses in all settings must take an active role in educating the patient and relieving anxiety. The nurse informs the patient what to expect, from administration of anesthesia to thoracotomy and the likely use of chest tubes and a drainage system in the postoperative period. The patient is also informed about the usual postoperative administration of oxygen to facilitate breathing, and the possible use of a ventilator. It is essential to explain the importance of frequent turning to promote drainage of lung secretions. Instruction in the use of incentive spirometry begins before surgery to familiarize the patient with its correct use. The nurse should teach diaphragmatic and pursed-lip breathing, and the patient should begin practicing these techniques (see Chart 25-3, “Breathing Exercises,” and Chart 25-4, “Assisting the Patient to Perform Incentive Spirometry”). Because a coughing schedule will be necessary in the postoperative period to promote the clearance or removal of secretions, the nurse instructs the patient in the technique of coughing and warns the patient that the coughing routine may be uncomfortable. The nurse teaches the patient to splint the incision with the hands, a pillow, or a folded towel (see Chart 25-5). Another technique, “huffing,” may be helpful for the patient with diminished expiratory flow rates or for the patient who refuses to cough because of severe pain. Huffing is the expulsion of air through an open glottis. This type of forced expiration technique (FET) stimulates pulmonary expansion and assists in alveolar inflation. The nurse instructs the patient as follows:
• Take a deep diaphragmatic breath and exhale forcefully against your hand in a quick, distinct pant, or huff.
• Practice doing small huffs and progress to one strong huff during exhalation.
Patients should be informed preoperatively that blood and other fluids may be administered, oxygen will be administered, and vital signs will be checked often for several hours after surgery. If a chest tube is needed, the patient should be informed that it will drain the fluid and air that normally accumulate after chest surgery. The patient and family are informed that the patient may be admitted to the intensive care unit for 1 to 2 days after surgery, that the patient may experience pain at the incision site, and that medication is available to relieve pain and discomfort (Finkelmeier, 2000).
Relieving Anxiety The nurse listens to the patient to evaluate his or her feelings about the illness and proposed treatment. The nurse also determines the patient’s motivation to return to normal or baseline function. The patient may reveal significant concerns: fear of hemorrhage because of bloody sputum, fear of discomfort from a chronic cough and chest pain, fear of ventilator dependence, or fear of death because of dyspnea and the underlying disease (eg, tumor). The nurse helps the patient to overcome these fears and to cope with the stress of surgery by correcting any misconceptions, supporting the patient’s decision to undergo surgery, reassuring the patient that the incision will “hold,” and dealing honestly with questions about pain and discomfort and their treatment. The management and control of pain begin before surgery, when the nurse informs the patient that many postoperative problems can be overcome by following certain routines related to deep breathing, coughing, turning, and moving. If patient-controlled analgesia or epidural analgesia is to be used after surgery, the nurse instructs the patient in its use.
POSTOPERATIVE MANAGEMENT After surgery the vital signs are checked frequently. Oxygen is administered by a mechanical ventilator, nasal cannula, or mask for as long as necessary. A reduction in lung capacity requires a period of physiologic adjustment, and fluids may be given at a low hourly rate to prevent fluid overload and pulmonary edema. When the patient is conscious and the vital signs have stabilized, the head of the bed may be elevated 30 to 45 degrees. Careful positioning of the patient is important. Following pneumonectomy, a patient is usually turned every hour from the back to the operative side and should not be completely turned to the unoperated side. This allows the fluid left in the space to consolidate and prevents the remaining lung and the heart from shifting (mediastinal shift) toward the operative side. The patient with a lobectomy may be turned to either side, and a patient with a segmental resection usually is not turned onto the operative side unless the surgeon prescribes this position (Finkelmeier, 2000). Medication for pain is needed for several days after surgery. Because coughing can be painful, patients should be taught to splint the chest. Exercises are resumed early in the postoperative
Chapter 25 period to facilitate lung ventilation. The nurse assesses for signs of complications, including cyanosis, dyspnea, and acute chest pain. These may indicate atelectasis and should be reported immediately. Increased temperature or white blood cell count may indicate an infection, and pallor and increased pulse may indicate internal hemorrhage. Dressings should be assessed for fresh bleeding.
Mechanical Ventilation Depending on the nature of the surgery, the patient’s underlying condition, the intraoperative course, and the depth of anesthesia, the patient may require mechanical ventilation after surgery. The physician is responsible for determining the ventilator settings and modes, as well as determining the overall method and pace of weaning. However, the physician, nurse, and respiratory therapist work together closely to assess the patient’s tolerance and weaning progress. Early extubation from mechanical ventilation can also lead to earlier removal of arterial lines (Zevola & Maier, 1999).
Chest Drainage A crucial intervention for improving gas exchange and breathing in the postoperative period is the proper management of chest drainage and the chest drainage system. After thoracic surgery, chest tubes and a closed drainage system are used to re-expand the involved lung and to remove excess air, fluid, and blood. Chest
Table 25-3
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drainage systems also are used in treatment of spontaneous pneumothorax and trauma resulting in pneumothorax. Table 25-3 describes and compares the main features of these systems. Management of chest drainage systems is explained in Chart 2518. Prevention of cardiopulmonary complications following thoracic surgery is discussed in Chart 25-19. The normal breathing mechanism operates on the principle of negative pressure; that is, the pressure in the chest cavity normally is lower than the pressure of the atmosphere, causing air to move into the lungs during inspiration. Whenever the chest is opened, there is a loss of negative pressure, which can result in the collapse of the lung. The collection of air, fluid, or other substances in the chest can compromise cardiopulmonary function and can also cause the lung to collapse. Pathologic substances that collect in the pleural space include fibrin, or clotted blood; liquids (serous fluids, blood, pus, chyle); and gases (air from the lung, tracheobronchial tree, or esophagus). Chest tubes may be inserted to drain fluid or air from any of the three compartments of the thorax (the right and left pleural spaces and the mediastinum). The pleural space, located between the visceral and parietal pleura, normally contains 20 mL or less of fluid, which helps to lubricate the visceral and parietal pleura. Surgical incision of the chest wall almost always causes some degree of pneumothorax (air accumulating in the pleural space) or hemothorax (build-up of serous fluid or blood in the pleural space). Air and fluid collect in the pleural space, restricting lung expansion and reducing gas exchange. Placement of a chest tube in the pleural space restores the negative intrathoracic pressure needed for lung re-expansion following surgery or trauma.
• Comparison of Chest Drainage Systems
TYPES OF CHEST DRAINAGE SYSTEMS
Traditional Water Seal Also referred to as wet suction
Dry Suction Water Seal Also referred to as dry suction
Dry Suction Also referred to as one-way valve system
DESCRIPTION
COMMENTS
Has 3 chambers: a collection chamber, water seal chamber (middle chamber), and wet suction control chamber
Requires that sterile fluid be instilled into water seal and suction chambers Has positive- and negative-pressure release valves Intermittent bubbling indicates that the system is functioning properly Additional suction can be added by connecting system to a suction source
Has 3 chambers: a collection chamber, water seal chamber (middle chamber), and wet suction control chamber
Requires that sterile fluid be instilled in water seal chamber at 2-cm level No need to fill suction chamber with fluid Suction pressure is set with a regulator Has positive- and negative-pressure release valves Has an indicator to signify that the suction pressure is adequate Quieter than traditional water seal systems
Has a one-way mechanical value that allows air to leave the chest and prevents air from moving back into the chest
No need to fill suction chamber with fluid; thus, can be set up quickly in an emergency Works even if knocked over, making it ideal for patients who are ambulatory
Chart 25-18 GUIDELINES FOR Managing Chest Drainage Systems NURSING INTERVENTIONS
RATIONALE
1. If using a chest drainage system with a water seal, fill the water seal chamber with sterile water to the level specified by the manufacturer. 2. When using suction in chest drainage systems with a water seal, fill the suction control chamber with sterile water to the 20-cm level or as prescribed. In systems without a water seal, set the regulator dial at the appropriate suction level. 3. Attach the drainage catheter exiting the thoracic cavity to the tubing coming from the collection chamber. Tape securely with adhesive tape. 4. If suction is used, connect the suction control chamber tubing to the suction unit. If using a wet suction system, turn on the suction unit and increase pressure until slow but steady bubbling appears in the suction control chamber. If using a chest drainage system with a dry suction control chamber, turn the regulator dial to 20 cm H2O.
Water seal drainage allows air and fluid to escape into a drainage chamber. The water acts as a seal and keeps the air from being drawn back into the pleural space. The water level regulator dial setting determines the degree of suction applied. In chest drainage units, the system is closed. The only connection is the one to the patient’s catheter. With a wet suction system, the degree of suction is determined by the amount of water in the suction control chamber and is not dependent on the rate of bubbling or the pressure gauge setting on the suction unit. With a dry suction control chamber, the regulator dial replaces the water.
Vent
30
SUCTION LEVEL 500
20 10 5
FILL LINE 0
450 350 300 250 200 150 100 50
2500ml Collection Unit
2500 2400 2300 2200 2100 2000 1900 1800 1700 1600 1500 1400 1300 1200 1100 1000 900 800 700 600
To suction From patient source or air Drainage Collection chamber
Vent to room air
20 cm 250 mm
Water seal
Suction Control
Example of a disposable chest drainage system.
5. Mark the drainage from the collection chamber with tape on the outside of the drainage unit. Mark hourly/daily increments (date and time) at the drainage level.
6. Ensure that the drainage tubing does not kink, loop, or interfere with the patient’s movements. 7. Encourage the patient to assume a comfortable position with good body alignment. With the lateral position, make sure that the patient’s body does not compress the tubing. The patient should be turned and repositioned every 1.5 to 2 hours. Provide adequate analgesia.
This marking shows the amount of fluid loss and how fast fluid is collecting in the drainage chamber. It serves as a basis for determining the need for blood replacement, if the fluid is blood. Visibly bloody drainage will appear in the chamber in the immediate postoperative period but should gradually becomes serous. If the patient is bleeding as heavily as 100 mL every 15 minutes, check the drainage every few minutes. A reoperation or autotransfusion may be needed. The transfusion of blood collected in the drainage chamber must be reinfused within 4 to 6 hours. Usually, however, drainage decreases progressively in the first 24 hours. Kinking, looping, or pressure on the drainage tubing can produce back-pressure, which may force fluid back into the pleural space or impede its drainage. Frequent position changes promote drainage, and good body alignment helps prevent postural deformities and contractures. Proper positioning also helps breathing and promotes better air exchange. Analgesics may be needed to promote comfort. (continued)
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Chart 25-18 GUIDELINES FOR Managing Chest Drainage Systems (Continued) NURSING INTERVENTIONS 8. Assist the patient with range-of-motion exercises for the affected arm and shoulder several times daily. Provide adequate analgesia. 9. Gently “milk” the tubing in the direction of the drainage chamber as needed. 10. Make sure there is fluctuation (“tidaling”) of the fluid level in the water seal chamber (in wet systems), or check the air leak indicator for leaks (in dry systems with a one-way valve). Note: Fluid fluctuations in the water seal chamber or air leak indicator area will stop when: • The lung has reexpanded • The tubing is obstructed by blood clots, fibrin, or kinks • A loop of tubing hangs below the rest of the tubing • Suction motor or wall suction is not working properly 11. With a dry system, assess for the presence of the indicator (bellows or float device) when setting the regulator dial to the desired level of suction. 12. Observe for air leaks in the drainage system; they are indicated by constant bubbling in the water seal chamber, or by the air leak indicator in dry systems with a one-way valve. Also assess the chest tube system for correctable external leaks. Notify the physician immediately of excessive bubbling in the water seal chamber not due to external leaks. 13. When turning down the dry suction, depress the manual highnegativity vent, and assess for a rise in the water level of the water seal chamber. 14. Observe and immediately report rapid and shallow breathing, cyanosis, pressure in the chest, subcutaneous emphysema, symptoms of hemorrhage, or significant changes in vital signs. 15. Encourage the patient to breathe deeply and cough at frequent intervals. Provide adequate analgesia. If needed, request an order for patient-controlled analgesia. Also teach the patient how to perform incentive spirometry. 16. If the patient is lying on a stretcher and must be transported to another area, place the drainage system below the chest level. If the tubing disconnects, cut off the contaminated tips of the chest tube and tubing, insert a sterile connector in the cut ends, and reattach to the drainage system. Do not clamp the chest tube during transport. 17. When assisting in the chest tube’s removal, instruct the patient to perform a gentle Valsalva maneuver or to breathe quietly. The chest tube is then clamped and quickly removed. Simultaneously, a small bandage is applied and made airtight with petrolatum gauze covered by a 4 × 4-inch gauze pad and thoroughly covered and sealed with nonporous tape.
The mediastinal space is an extrapleural space that lies between the right and left thoracic cavities. Mediastinal chest tubes promote the removal of blood or other fluid from around the heart (Finkelmeier, 2000). Accumulating fluid can stop the heart from beating if it is not drained. A mediastinal tube can be inserted either anteriorly or posteriorly to the heart to drain blood after surgery or trauma. Without a tube, compression of the heart could occur, leading to death (Carroll, 2000). There are two types of chest tubes: small-bore and large-bore catheters. Small-bore catheters (7F to 12F) have a one-way valve apparatus to prevent air from moving back into the patient. They can be inserted through a small skin incision. Large-bore catheters,
RATIONALE Exercise helps to prevent ankylosis of the shoulder and to reduce postoperative pain and discomfort. Analgesics may be needed to relieve pain. “Milking” prevents the tubing from becoming obstructed by clots and fibrin. Constant attention to maintaining the patency of the tube facilitates prompt expansion of the lung and minimizes complications. Fluctuation of the water level in the water seal shows effective connection between the pleural cavity and the drainage chamber and indicates that the drainage system remains patent. Fluctuation is also a gauge of intrapleural pressure in systems with a water seal (wet and dry, but not with the one-way valve). An air leak indicator shows changes in intrathoracic pressure in dry systems with a one-way valve. Bubbles will appear if a leak is present. The air leak indicator takes the place of fluid fluctuations in the water seal chamber. The indicator shows that the vacuum is adequate to maintain the desired level of suction. Leaking and trapping of air in the pleural space can result in tension pneumothorax.
A rise in the water level of the water seal chamber indicates high negative pressure in the system that could lead to increased intrathoracic pressure. Many clinical conditions can cause these signs and symptoms, including tension pneumothorax, mediastinal shift, hemorrhage, severe incisional pain, pulmonary embolus, and cardiac tamponade. Surgical intervention may be necessary. Deep breathing and coughing help to raise the intrapleural pressure, which promotes drainage of accumulated fluid in the pleural space. Deep breathing and coughing also promote removal of secretions from the tracheobronchial tree, which in turn promotes lung expansion and prevents atelectasis (alveolar collapse). The drainage apparatus must be kept at a level lower than the patient’s chest to prevent fluid from flowing backward into the pleural space. Clamping can result in a tension pneumothorax.
The chest tube is removed as directed when the lung is reexpanded (usually 24 hours to several days), depending on the cause of the pneumothorax. During tube removal, the chief priorities are preventing air from entering the pleural cavity as the tube is withdrawn and preventing infection.
which range in size up to 40F, are usually connected to a chest drainage system to collect any pleural fluid and monitor for air leaks (Scanlan, Wilkins & Stoller, 1999). After the chest tube is positioned, it is sutured to the skin and connected to a drainage apparatus to remove the residual air and fluid from the pleural or mediastinal space. This results in the re-expansion of remaining lung tissue. CHEST DRAINAGE SYSTEMS Chest drainage systems have a suction source, a collection chamber for pleural drainage, and a mechanism to prevent air from reentering the chest with inhalation. Various types of
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Chart 25-19
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Preventing Postoperative Cardiopulmonary Complications After Thoracic Surgery
Patient Management • Auscultate lung sounds and assess for rate, rhythm, and depth. • Monitor oxygenation with pulse oximetry. • Monitor electrocardiogram for rate and rhythm changes. • Assess capillary refill, skin color, and status of the surgical dressing. • Encourage and assist the patient to turn, cough, and take deep breaths. Chest Drainage Management • Verify that all connection tubes are patent and connected securely. • Assess that the water seal is intact when using a wet suction system and assess the regulator dial in dry suction systems. • Monitor characteristics of drainage including color, amount, and consistency. Assess for significant increases or decreases in drainage output. • Note fluctuations in the water seal chamber for wet suction systems and the air leak indicator for dry suction systems. • Keep system below the patient’s chest level. • Assess suction control chamber for bubbling in wet suction systems. • Keep suction at level ordered. • Maintain appropriate fluid in water seal for wet suction systems. • Keep air vent open when suction is off.
chest drainage systems are available for use in removal of air and fluid from the pleural space and re-expansion of the lungs. Chest drainage systems come with either wet (water seal) or dry suction control. In wet suction systems, the amount of suction is determined by the amount of water instilled in the suction chamber. The amount of bubbling in the suction chamber indicates how strong the suction is. Wet systems use a water seal to prevent air from moving back into the chest on inspiration. Dry systems use a one-way valve and a suction control dial in place of the water needed with wet or water seal system. Both systems can operate by gravity drainage, without a suction source. Water Seal Chest Drainage Systems. The traditional water seal chest drainage system (or wet suction) has three chambers: a collection chamber, a water seal chamber, and a wet suction control chamber. The collection chamber acts as a reservoir for fluid draining from the chest tube. It is graduated to permit easy measurement of drainage. Suction may be added to create negative pressure and promote drainage of fluid and removal of air. The suction control chamber regulates the amount of negative pressure applied to the chest. The amount of suction is determined by the water level. It is generally set at 20-cm water; adding more fluid results in more suction. After the suction is turned on, bubbling appears in the suction chamber. A positivepressure valve is located at the top of the suction chamber that automatically opens with increases in positive pressure within the system. Air will automatically be released through a positive-pressure relief valve if the suction tubing is inadvertently clamped or kinked. The water seal chamber has a one-way valve or water seal that prevents air from moving back into the chest when the patient in-
hales. There will be an increase in the water level with inspiration and a return to the baseline level during exhalation; this is referred to as tidaling. Intermittent bubbling in the water seal chamber is normal, but continuous bubbling can indicate an air leak. Bubbling and tidaling do not occur when the tube is placed in the mediastinal space; however, fluid may pulsate with the patient’s heartbeat. If the chest tube is connected to gravity drainage only, suction is not used. The pressure is equal to the water seal only. Two-chamber chest drainage systems (water seal chamber and collection chamber) are available for use with patients who need only gravity drainage. The water level in the water seal chamber reflects the negative pressure present in the intrathoracic cavity. A rise in the water level indicates negative pressure in the pleural or mediastinal space. Excessive negative pressure can cause trauma to tissue (Bar-El, Ross, Kablawi & Egenburg, 2001). Most chest drainage systems have an automatic means to prevent excessive negative pressure. By pressing and holding a manual high-negativity vent (usually located on the top of the chest drainage system) until the water level in the water seal chamber returns to the 2-cm mark, excessive negative pressure is avoided, preventing damage to tissue.
!
NURSING ALERT When the wall vacuum is turned off, the drainage system must be open to the atmosphere so that intrapleural air can escape from the system. This can be done by detaching the tubing from the suction port to provide a vent.
!
NURSING ALERT If the chest tube and drainage system become disconnected, air can enter the pleural space, producing a pneumothorax. To prevent pneumothorax if the chest tube is inadvertently disconnected from the drainage system, a temporary water seal can be established by immersing the chest tube’s open end in a bottle of sterile water.
Dry Suction Water Seal Systems. Dry suction water seal systems, also referred to as dry suction, have a collection chamber for drainage, a water seal chamber, and a dry suction control chamber. The water seal chamber is filled with water to the 2-cm level. Bubbling in this area can indicate an air leak. The dry suction control chamber contains a regulator dial that conveniently regulates vacuum to the chest drain. Water is not needed for suction as it is in the wet system. Without the bubbling in the suction chamber, the machine is quieter. Once the tube is connected to the suction source, the regulator dial allows the desired level of suction to be dialed in; the suction is increased until an indicator appears. The indicator has the same function as the bubbling in the traditional water seal system; that is, it indicates that the vacuum is adequate to maintain the desired level of suction. Some drainage systems use a bellows (a chamber that can be expanded or contracted) or an orangecolored float device as an indicator of when the suction control regulator is set. When the water in the water seal rises above the 2-cm level, intrathoracic pressure increases. Dry suction water seal systems have a manual high-negativity vent located on top of the drain. Pressing the manual high-negativity vent until the indicator appears (either a float device or bellows) and the water level in the water seal returns to the desired level, intrathoracic pressure is decreased.
Chapter 25
!
NURSING ALERT The manual vent should not be used to lower the water level in the water seal when the patient is on gravity drainage (no suction) because intrathoracic pressure is equal to the pressure in the water seal.
Respiratory Care Modalities
633
• Impaired physical mobility of the upper extremities related to thoracic surgery
• Risk for imbalanced fluid volume related to the surgical procedure
• Imbalanced nutrition, less than body requirements related to dyspnea and anorexia
Dry Suction with a One-Way Valve System. A third type of chest drainage system is dry suction with a one-way mechanical valve. This system has a collection chamber, a one-way mechanical valve, and a dry suction control chamber. The valve acts in the same way as a water seal and permits air to leave the chest but prevents it from moving back into the pleural space. This model lacks a water seal chamber and therefore has the advantage of a system that operates without water. For example, it can be set up quickly in emergency situations, and the dry control drain will still work even if it is knocked over. If the wet suction drain is knocked over, the water seal could be lost. This makes the dry suction systems useful for the patient who is ambulating or being transported. However, without the water seal chamber, there is no way to tell by inspection if the pressure in the chest has changed. An air leak indicator is present so that the system can be checked for air leaks. If an air leak is suspected, 30 mL of water are injected into the air leak indicator. Bubbles will appear if a leak is present (Carroll, 2000).
NURSING PROCESS: THE PATIENT UNDERGOING THORACIC SURGERY Postoperative Assessment The nurse monitors the heart rate and rhythm by auscultation and electrocardiography because episodes of major dysrhythmias are common after thoracic and cardiac surgery. In the immediate postoperative period, an arterial line may be maintained to allow frequent monitoring of arterial blood gases, serum electrolytes, hemoglobin and hematocrit values, and arterial pressure. Central venous pressure may be monitored to detect early signs of fluid volume disturbances. Central venous pressure monitoring devices are being used less frequently and for shorter periods of time than in the past. Early extubation from mechanical ventilation can also lead to earlier removal of arterial lines (Zevola & Maier, 1999). Another important component of postoperative assessment is to note the results of the preoperative evaluation of the patient’s lung reserve by pulmonary function testing. A preoperative FEV1 of more than 2 L or more than 70% of predicted value indicates a good lung reserve. Patients who have a postoperative predicted FEV1 of less than 40% of predicted value have a higher incidence of morbidity and mortality (Scanlan, Wilkins & Stoller, 1999). This results in decreased tidal volumes, placing the patient at risk for respiratory failure.
Diagnosis NURSING DIAGNOSES Based on the assessment data, the patient’s major postoperative nursing diagnoses may include:
• Impaired gas exchange related to lung impairment and surgery
• Ineffective airway clearance related to lung impairment, anesthesia, and pain
• Acute pain related to incision, drainage tubes, and the surgical procedure
• Deficient knowledge about self-care procedures at home COLLABORATIVE PROBLEMS/ POTENTIAL COMPLICATIONS Based on assessment data, potential complications may include:
• • • • •
Respiratory distress Dysrhythmias Atelectasis, pneumothorax, and bronchopleural fistula Blood loss and hemorrhage Pulmonary edema
Planning and Goals The major goals for the patient may include improvement of gas exchange and breathing, improvement of airway clearance, relief of pain and discomfort, increased arm and shoulder mobility, maintenance of adequate fluid volume and nutritional status, understanding of self-care procedures, and absence of complications.
Nursing Interventions IMPROVING GAS EXCHANGE AND BREATHING Gas exchange is determined by evaluating oxygenation and ventilation. In the immediate postoperative period, this is achieved by measuring vital signs (blood pressure, pulse, and respirations) at least every 15 minutes for the first 1 to 2 hours, then less frequently as the patient’s condition stabilizes. Pulse oximetry is used for continuous monitoring of the adequacy of oxygenation. It is important to draw blood for arterial blood gas measurements early in the postoperative period to establish a baseline to assess the adequacy of oxygenation and ventilation and the possible retention of CO2. The frequency with which postoperative arterial blood gases are measured depends on whether the patient is mechanically ventilated or exhibits signs of respiratory distress; these measurements can help determine appropriate therapy. It also is common practice for patients to have an arterial line in place to obtain blood for blood gas measurements and to monitor blood pressure closely. Hemodynamic monitoring may be used to assess hemodynamic stability. Breathing techniques, such as diaphragmatic and pursed-lip breathing, that were taught before surgery should be performed by the patient every 2 hours to expand the alveoli and prevent atelectasis. Another technique to improve ventilation is sustained maximal inspiration therapy or incentive spirometry. This technique promotes lung inflation, improves the cough mechanism, and allows early assessment of acute pulmonary changes. (See Charts 25-3 and 25-4 for more information.) Positioning also improves breathing. When the patient is oriented and blood pressure is stabilized, the head of the bed is elevated 30 to 40 degrees during the immediate postoperative period. This facilitates ventilation, promotes chest drainage from the lower chest tube, and helps residual air to rise in the upper portion of the pleural space, where it can be removed through the upper chest tube. The nurse should consult with the surgeon about patient positioning. There is controversy regarding the best side-lying position. In general, the patient should be positioned from back to
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side frequently and moved from horizontal to semi-upright position as soon as tolerated. Most commonly, the patient is instructed to lie on the operative side. However, the patient with unilateral lung pathology may not be able to turn well onto that side because of pain. In addition, positioning the patient with the “good lung” (the nonoperated lung) down allows a better match of ventilation and perfusion and therefore may actually improve oxygenation. The patient’s position is changed from horizontal to semi-upright as soon as possible, because remaining in one position tends to promote the retention of secretions in the dependent portion of the lungs. After a pneumonectomy, the operated side should be dependent so that fluid in the pleural space remains below the level of the bronchial stump, and the other lung can fully expand. The procedure for turning the patient is as follows:
• Instruct the patient to bend the knees and use the feet to push. • Have the patient shift hips and shoulders to the opposite side of the bed while pushing with the feet.
• Bring the patient’s arm over the chest, pointing it in the di•
rection toward which the patient is being turned. Have the patient grasp the side rail with the hand. Turn the patient in log-roll fashion to prevent twisting at the waist and pain from possible pulling on the incision.
IMPROVING AIRWAY CLEARANCE Retained secretions are a threat to the thoracotomy patient after surgery. Trauma to the tracheobronchial tree during surgery, diminished lung ventilation, and diminished cough reflex all result in the accumulation of excessive secretions. If the secretions are retained, airway obstruction occurs. This, in turn, causes the air in the alveoli distal to the obstruction to become absorbed and the affected portion of the lung to collapse. Atelectasis, pneumonia, and respiratory failure may result. Several techniques are used to maintain a patent airway. First, secretions are suctioned from the tracheobronchial tree before the endotracheal tube is discontinued. Secretions continue to be removed by suctioning until the patient can cough up secretions effectively. Nasotracheal suctioning may be needed to stimulate a deep cough and aspirate secretions that the patient cannot cough up. However, it should be used only after other methods to raise secretions have been unsuccessful (Chart 25-20). Coughing technique is another measure used in maintaining a patent airway. The patient is encouraged to cough effectively; ineffective coughing results in exhaustion and retention of secretions (see Chart 25-5). To be effective, the cough must be low-pitched, deep, and controlled. Because it is difficult to cough in a supine position, the patient is helped to a sitting position on the edge of the bed, with the feet resting on a chair. The patient should cough at least every hour during the first 24 hours and when necessary thereafter. If audible crackles are present, it may be necessary to use chest percussion with the cough routine until the lungs are clear. Aerosol therapy is helpful in humidifying and mobilizing secretions so that they can easily be cleared with coughing. To minimize incisional pain during coughing, the nurse supports the incision or encourages the patient to do so (Fig. 25-8). After helping the patient to cough, the nurse should listen to both lungs, anteriorly and posteriorly, to determine whether there are any changes in breath sounds. Diminished breath sounds may indicate collapsed or hypoventilated alveoli.
Chart 25-20
Performing Nasotracheal Suction
Sterile Technique to Be Used 1. Explain procedure to the patient. 2. Medicate patient for pain if necessary. 3. Place the patient in a sitting or semi-Fowler’s position. Make sure the patient’s head is not flexed forward. Remove excess pillows if necessary. 4. Oxygenate the patient several minutes before initiating the suctioning procedure. Have oxygen source ready nearby during procedure. 5. Put on sterile gloves. 6. Lubricate catheter with water-soluble gel. 7. Gently pass catheter through the patient’s nose to the pharynx. If it is difficult to pass the catheter, and repeated suctioning is expected, a soft rubber nasal trumpet may be placed nasopharyngeally to provide easier catheter passage. Check the position of the tip of the catheter by asking the patient to open the mouth and inspecting it; the tip of the catheter should be in the lower pharynx. 8. Instruct the patient to take a deep breath or stick out the tongue. This action opens the epiglottis and promotes downward movement of the catheter. 9. Advance the catheter into the trachea only during inspiration. Listen for cough or for passage of air through the catheter. 10. Attach the catheter to suction apparatus. Apply intermittent suction while slowly withdrawing the catheter. Do not let suction exceed 120 mm Hg. 11. Do not suction for longer than 10 to 15 seconds, as dysrhythmias, bradycardia, or cardiac arrest may occur in patients with borderline oxygenation. 12. If additional suctioning is needed, withdraw the catheter to the back of the pharynx. Reassure patient and oxygenate for several minutes before resuming suctioning.
Chest physiotherapy is the final technique for maintaining a patent airway. If a patient is identified as being at high risk for developing postoperative pulmonary complications, then chest physiotherapy is started immediately (perhaps even before surgery). The techniques of postural drainage, vibration, and percussion help to loosen and mobilize the secretions so that they can be coughed up or suctioned. RELIEVING PAIN AND DISCOMFORT Pain after a thoracotomy may be severe, depending on the type of incision and the patient’s reaction to and ability to cope with pain. Deep inspiration is very painful after thoracotomy. Pain can lead to postoperative complications if it reduces the patient’s ability to breathe deeply and cough, and if it further limits chest excursions so that ventilation becomes ineffective. Immediately after the surgical procedure and before the incision is closed, the surgeon may perform a nerve block with a longacting local anesthetic such as bupivacaine (Marcaine, Sensorcaine). Bupivacaine is titrated to relieve postoperative pain while allowing the patient to cooperate in deep breathing, coughing, and mobilization. However, it is important to avoid depressing the respiratory system with excessive analgesia: the patient should not be so sedated as to be unable to cough. There is controversy about the effectiveness of injections of local anesthetic for pain relief after thoracotomy surgery. Research has shown that bupivacaine was no
Chapter 25
A The nurse’s hands should support the chest incision anteriorly and posteriorly. The patient is instructed to take several deep breaths, inhale, and then cough forcibly.
FIGURE 25-8 Techniques for supporting incision while a patient recovering from thoracic surgery coughs.
more effective than saline injections in treating postoperative thoracotomy pain (Silomon et al., 2000). Lidocaine and prilocaine are local anesthetic agents used to treat pain at the site of the chest tube insertion. These medications are administered as topical transdermal analgesics that penetrate the skin. Lidocaine and prilocaine have also been found to be effective when used together. EMLA cream, which is a mixture of the two medications, has been found to be effective in treating pain from chest tube removal, and recent studies found it to be more effective than intravenous morphine (Valenzuela & Rosen, 1999). Because of the need to maximize patient comfort without depressing the respiratory drive, patient-controlled analgesia (PCA) is often used. Opioid analgesic agents such as morphine are commonly used. PCA, administered through an intravenous pump or an epidural catheter, allows the patient to control the frequency and total dosage. Preset limits on the pump avoid overdosage. With proper instruction, these methods are well tolerated and allow earlier mobilization and cooperation with the treatment regimen. (See Chap. 13 for a more extensive discussion of PCA and pain management.)
!
NURSING ALERT It is important not to confuse the restlessness of hypoxia with the restlessness caused by pain. Dyspnea, restlessness, increasing respiratory rate, increasing blood pressure, and tachycardia are warning signs of impending respiratory insufficiency. Pulse oximetry is used to monitor oxygenation and to differentiate causes of restlessness.
Respiratory Care Modalities
B With one hand, the nurse exerts downward pressure on the shoulder of the affected side while firmly supporting the area beneath the wound with the other hand. The patient is instructed to take several deep breaths, inhale, and then cough forcibly.
635
C The nurse can wrap a towel or sheet around the patient’s chest and hold the ends together, pulling slightly as the patient coughs, and releasing during deep breaths.
D The patient can be taught to hold a pillow firmly against the incision while coughing. This can be done while lying down or sitting in an upright position.
PROMOTING MOBILITY AND SHOULDER EXERCISES Because large shoulder girdle muscles are transected during a thoracotomy, the arm and shoulder must be mobilized by full range of motion of the shoulder. As soon as physiologically possible, usually within 8 to 12 hours, the patient is helped to get out of bed. Although this may be painful initially, the earlier the patient moves, the sooner the pain will subside. In addition to getting out of bed, the patient begins arm and shoulder exercises to restore movement and prevent painful stiffening of the affected arm and shoulder (Chart 25-21). MAINTAINING FLUID VOLUME AND NUTRITION Intravenous Therapy During the surgical procedure or immediately after, the patient may receive a transfusion of blood products, followed by a continuous intravenous infusion. Because a reduction in lung capacity often occurs following thoracic surgery, a period of physiologic adjustment is needed. Fluids should be administered at a low hourly rate and titrated (as prescribed) to prevent overloading the vascular system and precipitating pulmonary edema. The nurse performs careful respiratory and cardiovascular assessments, as well as intake and output, vital signs, and assessment of jugular vein distention. The nurse should also monitor the infusion site for signs of infiltration, including swelling, tenderness, and redness. Diet It is not unusual for patients undergoing thoracotomy to have poor nutritional status before surgery because of dyspnea, sputum production, and poor appetite. Therefore, it is especially important
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Chart 25-21
• PATIENT EDUCATION Performing Arm and Shoulder Exercises Arm and shoulder exercises are performed after thoracic surgery to restore movement, prevent painful stiffening of the shoulder, and improve muscle power.
A
D
B
C
E
F
that adequate nutrition be provided. A liquid diet is provided as soon as bowel sounds return; the patient is progressed to a full diet as soon as possible. Small, frequent meals are better tolerated and are crucial to the recovery and maintenance of lung function. MONITORING AND MANAGING POTENTIAL COMPLICATIONS Complications after thoracic surgery are always a possibility and must be identified and managed early. In addition, the nurse monitors the patient at regular intervals for signs of respiratory distress or developing respiratory failure, dysrhythmias, bronchopleural fistula, hemorrhage and shock, atelectasis, and pulmonary infection. Respiratory distress is treated by identifying and eliminating its cause while providing supplemental oxygen. If the patient progresses to respiratory failure, intubation and mechanical ventilation are necessary, eventually requiring weaning. Dysrhythmias are often related to the effects of hypoxia or the surgical procedure. They are treated with antiarrhythmic medication and supportive therapy (see Chap. 27). Pulmonary infec-
(A) Hold hand of the affected side with the other hand, palms facing in. Raise the arms forward, upward, and then overhead, while taking a deep breath. Exhale while lowering the arms. Repeat five times. (B) Raise arm sideward, upward, and downward in a waving motion. (C) Place arm at side. Raise arm sideward, upward, and over the head. Repeat five times. These exercises can also be performed while lying in bed. (D) Extend the arm up and back, out to the side and back, down at the side and back. (E) Place hands in small of back. Push elbows as far back as possible. (F) Sit erect in an armchair; place the hands on the arms of the chair directly opposite the sides of the body. Press down on hands, consciously pulling the abdomen in and stretching up from the waist. Inhale while raising the body until the elbows are extended completely. Hold this position a moment, and begin exhaling while lowering the body slowly to the original position.
tions or effusion, often preceded by atelectasis, may occur a few days into the postoperative course. Pneumothorax may occur following thoracic surgery if there is an air leak from the surgical site to the pleural cavity or from the pleural cavity to the environment. Failure of the chest drainage system will prevent return of negative pressure in the pleural cavity and result in pneumothorax. In the postoperative patient pneumothorax is often accompanied by hemothorax. The nurse maintains the chest drainage system and monitors the patient for signs and symptoms of pneumothorax: increasing shortness of breath, tachycardia, increased respiratory rate, and increasing respiratory distress. Bronchopleural fistula is a serious but rare complication preventing the return of negative intrathoracic pressure and lung reexpansion. Depending on its severity, it is treated with closed chest drainage, mechanical ventilation, and possibly talc pleurodesis (described in Chap. 23). Hemorrhage and shock are managed by treating the underlying cause, whether by reoperation or by administration of blood products or fluids. Pulmonary edema from overinfusion of intravenous fluids is a significant danger. The early symptoms are dys-
Chapter 25 pnea, crackles, bubbling sounds in the chest, tachycardia, and pink, frothy sputum. This constitutes an emergency and must be reported and treated immediately. PROMOTING HOME AND COMMUNITY-BASED CARE Teaching Patients Self-Care The nurse instructs the patient and family about postoperative care that will be continued at home. The nurse explains signs and symptoms that should be reported to the physician. These include:
• Change in respiratory status: increasing shortness of breath,
• •
fever, increased restlessness or other changes in mental or cognitive status, increased respiratory rate, change in respiratory pattern, change in amount or color of sputum Bleeding or other drainage from the surgical incision or chest tube exit sites Increased chest pain
In addition, respiratory care and other treatment modalities (oxygen, incentive spirometer, chest physiotherapy, and oral, inhaled, or intravenous medications) may be continued at home. Therefore, the nurse needs to instruct the patient and family in their correct and safe use. The nurse emphasizes the importance of progressively increased activity. The nurse instructs the patient to ambulate within limits and explains that return of strength is likely to be very gradual. Another important aspect of patient teaching addresses shoulder exercises. It is important to instruct the patient to do these exercises five times daily. Additional patient teaching is described in Chart 25-22. Continuing Care Depending on the patient’s physical status and the availability of family assistance, a home care referral may be indicated. The home care nurse assesses the patient’s recovery from surgery, with special attention to respiratory status, the surgical incision, chest drainage, pain control, ambulation, and nutritional status. The patient’s use of respiratory modalities should be assessed to ensure they are being used correctly and safely. In addition, the nurse assesses the patient’s compliance with the
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postoperative treatment plan and identifies acute or late postoperative complications. The recovery process may be longer than the patient had expected, and providing support to the patient is an important task for the home care nurse. Because of shorter hospital stays, attending follow-up physician appointments is essential. The nurse teaches the patient about the importance of keeping follow-up appointments and completing laboratory tests as prescribed to assist the physician in evaluating recovery. The home care nurse provides continuous encouragement and education to the patient and family during the process. As recovery progresses, the nurse also reminds the patient and family about the importance of participating in health promotion activities and recommended health screening.
Evaluation EXPECTED PATIENT OUTCOMES Expected patient outcomes may include: 1. Demonstrates improved gas exchange, as reflected in arterial blood gas measurements, breathing exercises, and use of incentive spirometry 2. Shows improved airway clearance, as evidenced by deep, controlled coughing and clear breath sounds or decreased presence of adventitious sounds 3. Has decreased pain and discomfort by splinting incision during coughing and increasing activity level 4. Shows improved mobility of shoulder and arm; demonstrates arm and shoulder exercises to relieve stiffening 5. Maintains adequate fluid intake and maintains nutrition for healing 6. Exhibits less anxiety by using appropriate coping skills, and demonstrates a basic understanding of technology used in care 7. Adheres to therapeutic program and home care 8. Is free of complications, as evidenced by normal vital signs and temperature, improved arterial blood gas measurements, clear lung sounds, and adequate respiratory function For a detailed plan of nursing care for the patient who has had a thoracotomy, see the Plan of Nursing Care.
Chart 25-22 Home Care Checklist • The Patient With a Thoracotomy At the completion of the home care instruction, the patient or caregiver will be able to: • Use local heat and oral analgesia to relieve intercostal pain. • Alternate walking and other activities with frequent rest periods, expecting weakness and fatigue for the first 3 weeks. • Perform breathing exercises several times daily for the first few weeks at home. • Avoid lifting more than 20 pounds until complete healing has taken place; the chest muscles and incision may be weaker than normal for 3 to 6 months after surgery. • Walk at a moderate pace, gradually and persistently extending walking time and distance. • Immediately stop any activity that causes undue fatigue, increased shortness of breath, or chest pain. • Avoid bronchial irritants (smoke, fumes, air pollution, aerosol sprays). • Avoid others with known colds or lung infections. • Obtain an annual influenza vaccine and discuss vaccination against pneumonia with the physician. • Report for follow-up care by the surgeon or clinic as necessary. • Stop smoking, if applicable.
Patient
Caregiver
✓ ✓ ✓
✓ ✓
✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓
✓ ✓ ✓ ✓
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Plan of Nursing Care Care of the Patient After Thoracotomy Nursing Interventions
Rationale
Expected Patient Outcomes
Nursing Diagnosis: Impaired gas exchange related to lung impairment and surgery Goal: Improvement of gas exchange and breathing 1. Monitor pulmonary status as directed and as needed: a. Auscultate breath sounds. b. Check rate, depth, and pattern of respirations. c. Assess blood gases for signs of hypoxemia or CO2 retention. d. Evaluate patient’s color for cyanosis. 2. Monitor and record blood pressure, apical pulse, and temperature every 2–4 hours, central venous pressure (if indicated) every 2 hours. 3. Monitor continuous electrocardiogram for pattern and dysrhythmias.
4. Elevate head of bed 30–40 degrees when patient is oriented and hemodynamic status is stable. 5. Encourage deep-breathing exercises (see section on Breathing Retraining) and effective use of incentive spirometer (sustained maximal inspiration). 6. Encourage and promote an effective cough routine to be performed every 1–2 hours during first 24 hours. 7. Assess and monitor the chest drainage system:* a. Assess for leaks and patency as needed. b. Monitor amount and character of drainage and document every 2 hours. Notify physician if drainage is 150 mL/h or greater. c. See Chart 25-18 for summary of nurse’s role in management of chest drainage systems.
1. Changes in pulmonary status indicate improvement or onset of complications.
• Lungs are clear on auscultation • Respiratory rate is within acceptable range with no episodes of dyspnea
• Vital signs are stable • Dysrhythmias are not present or are under control
• Demonstrates deep, controlled, effective 2. Aid in evaluating effect of surgery on cardiac status. 3. Dysrhythmias (especially atrial fibrillation and atrial flutter) are more frequently seen after thoracic surgery. A patient with total pneumonectomy is especially prone to cardiac irregularity. 4. Maximum lung excursion is achieved when patient is as close to upright as possible. 5. Helps to achieve maximal lung inflation and to open closed airways.
• • •
breathing to allow maximal lung expansion Uses incentive spirometer every 2 hours while awake Demonstrates deep, effective coughing technique Lungs are expanded to capacity (evidenced by chest x-ray)
6. Coughing is necessary to remove retained secretions. 7. System is used to eliminate any residual air or fluid after thoracotomy.
Nursing Diagnosis: Ineffective airway clearance related to lung impairment, anesthesia, and pain Goal: Improvement of airway clearance and achievement of a patent airway 1. Maintain an open airway. 2. Perform endotracheal suctioning until patient can raise secretions effectively.
3. Assess and medicate for pain. Encourage deep-breathing and coughing exercises. Help splint incision during coughing.
1. Provides for adequate ventilation and gas exchange 2. Endotracheal secretions are present in excessive amounts in post-thoracotomy patients due to trauma to the tracheobronchial tree during surgery, diminished lung ventilation, and cough reflex. 3. Helps to achieve maximal lung inflation and to open closed airways. Coughing is painful; incision needs to be supported.
• • • • •
Airway is patent Coughs effectively Splints incision while coughing Sputum is clear or colorless Lungs are clear on auscultation
*A patient with a pneumonectomy usually does not have water seal chest drainage because it is desirable that the pleural space fill with an effusion, which eventually obliterates this space. Some surgeons do use a modified water seal system.
(continued)
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Plan of Nursing Care Care of the Patient After Thoracotomy (Continued) Nursing Interventions
Rationale
4. Monitor amount, viscosity, color, and odor of sputum. Notify physician if sputum is excessive or contains bright-red blood.
4. Changes in sputum suggest presence of infection or change in pulmonary status. Colorless sputum is not unusual; opacification or coloring of sputum may indicate dehydration or infection. 5. Secretions must be moistened and thinned if they are to be raised from the chest with the least amount of effort. 6. Chest physiotherapy uses gravity to help remove secretions from the lung.
5. Administer humidification and mininebulizer therapy as prescribed. 6. Perform postural drainage, percussion, and vibration as prescribed. Do not percuss or vibrate directly over operative site. 7. Auscultate both sides of chest to determine changes in breath sounds.
Expected Patient Outcomes
7. Indications for tracheal suctioning are determined by chest auscultation.
Nursing Diagnosis: Acute pain related to incision, drainage tubes, and the surgical procedure Goal: Relief of pain and discomfort 1. Evaluate location, character, quality, and severity of pain. Administer analgesic medication as prescribed and as needed. Observe for respiratory effect of opioid. Is patient too somnolent to cough? Are respirations depressed? 2. Maintain care postoperatively in positioning the thoracotomy patient: a. Place patient in semi-Fowler’s position. b. Patients with limited respiratory reserve may not be able to turn on unoperated side. c. Assist or turn patient every 2 hours. 3. Assess incision area every 8 hours for redness, heat, induration, swelling, separation, and drainage. 4. Request order for patient-controlled analgesia pump if appropriate for patient.
1. Pain limits chest excursions and thereby decreases ventilation.
• Asks for pain medication, but verbalizes •
2. The patient who is comfortable and free of pain will be less likely to splint the chest while breathing. A semi-Fowler’s position permits residual air in the pleural space to rise to upper portion of pleural space and be removed via the upper chest catheter.
•
that he or she expects some discomfort while deep breathing and coughing Verbalizes that he or she is comfortable and not in acute distress No signs of incisional infection evident
3. These signs indicate possible infection. 4. Allowing patient control over frequency and dose improves comfort and compliance with treatment regimen.
Nursing Diagnosis: Anxiety related to outcomes of surgery, pain, technology Goal: Reduction of anxiety to a manageable level 1. Explain all procedures in understandable language. 2. Assess for pain and medicate, especially before potentially painful procedures. 3. Silence all unnecessary alarms on technology (monitors, ventilators). 4. Encourage and support patient while increasing activity level. 5. Mobilize resources (family, clergy, social worker) to help patient cope with outcomes of surgery (diagnosis, change in functional abilities).
1. Explaining what can be expected in understandable terms decreases anxiety and increases cooperation. 2. Premedication before painful procedures or activities improves comfort and minimizes undue anxiety. 3. Unnecessary alarms increase the risk of sensory overload and may increase anxiety. 4. Positive reinforcement improves patient motivation and independence. 5. A multidisciplinary approach promotes the patient’s strengths and coping mechanisms.
• States that anxiety is at a manageable level • Participates with health care team in treatment regimen
• Uses appropriate coping skills (verbaliza•
tion, pain relief strategies, use of support systems such as family, clergy) Demonstrates basic understanding of technology used in care
(continued)
Plan of Nursing Care Care of the Patient After Thoracotomy (Continued) Nursing Interventions
Rationale
Expected Patient Outcomes
Nursing Diagnosis: Impaired physical mobility of the upper extremities related to thoracic surgery Goal: Increased mobility of the affected shoulder and arm 1. Assist patient with normal range of motion and function of shoulder and trunk: a. Teach breathing exercises to mobilize thorax. b. Encourage skeletal exercises to promote abduction and mobilization of shoulder (see Chart 25-21). c. Assist out of bed to chair as soon as pulmonary and circulatory systems are stable (usually by evening of surgery). 2. Encourage progressive activities according to level of fatigue.
1. Necessary to regain normal mobility of arm and shoulder and to speed recovery and minimize discomfort
• Demonstrates arm and shoulder exercises •
and verbalizes intent to perform them on discharge Regains previous range of motion in shoulder and arm
2. Increases patient’s use of affected shoulder and arm
Nursing Diagnosis: Risk for imbalanced fluid volume related to the surgical procedure Goal: Maintenance of adequate fluid volume 1. Monitor and record hourly intake and output. Urine output should be at least 30 mL h after surgery. 2. Administer blood component therapy and parenteral fluids and/or diuretics as prescribed to restore and maintain fluid volume.
1. Fluid management may be altered before, during, and after surgery, and patient’s response to and need for fluid management must be assessed. 2. Pulmonary edema due to transfusion or fluid overload is an ever-present threat; after pneumonectomy, the pulmonary vascular system has been greatly reduced.
• Patient is adequately hydrated, as evi-
denced by: • Urine output greater than 30 mL/h • Vital signs stable, heart rate, and central venous pressure approaching normal • No excessive peripheral edema
Nursing Diagnosis: Deficient knowledge of home care procedures Goal: Increased ability to carry out care procedures at home 1. Encourage patient to practice arm and shoulder exercises five times daily at home. 2. Instruct patient to practice assuming a functionally erect position in front of a full-length mirror. 3. Instruct patient in following aspects of home care: a. Relieve intercostal pain by local heat or oral analgesia. b. Alternate activities with frequent rest periods. c. Practice breathing exercises at home. d. Avoid heavy lifting until complete healing has occurred. e. Avoid undue fatigue, increased shortness of breath, or chest pain. f. Avoid bronchial irritants. g. Prevent colds or lung infection. h. Get annual influenza vaccine. i. Keep follow-up appointment with physician. j. Stop smoking.
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1. Exercise accelerates recovery of muscle function and reduces long-term pain and discomfort. 2. Practice will help restore normal posture. 3. Knowing what to expect facilitates recovery. a. Some soreness may persist for several weeks. b. Weakness and fatigue are common for the first 3 weeks or longer. c. Effective breathing is necessary to prevent splinting of affected side, which may lead to atelectasis. d. Chest muscles and incision may be weaker than normal for 3–6 months. e. Undue stress may prolong the healing process. f. The lung is more susceptible to irritants. g. The lung is more susceptible to infection during the recovery phase. h. Vaccination helps prevent flu. i. This allows timely follow-up assessment. j. Smoking will slow healing process by decreasing oxygen delivery to tissues and make lung susceptible to infection and other complications.
• Demonstrates arm and shoulder exercises • Verbalizes need to try to assume an erect posture
• Verbalizes the importance of relieving
discomfort, alternating walking and rest, performing breathing exercises, avoiding heavy lifting, avoiding undue fatigue, avoiding bronchial irritants, preventing colds or lung infections, getting flu vaccine, keeping follow-up visits, and stopping smoking
Chapter 25
?
Critical Thinking Exercises
1.
Oxygen therapy is required for the following patients: a 45-year-old patient who has undergone a right lower lobe lobectomy and needs short-term, low-flow oxygen; a 62-year-old patient with severe COPD admitted to the hospital for the fourth time in the past year; and a 74-yearold patient with dyspnea secondary to advanced lung cancer. Describe the explanations and safety precautions indicated for each of these patients and their families.
2.
Your patient has just returned from the operating room after chest surgery with an endotracheal tube, a chest tube, and two intravenous lines and cardiac monitoring in place. Identify the priorities of assessment and interventions for this patient.
3.
Your patient, who underwent a thoracotomy less than 24 hours ago, has a chest tube in place on the right side. Identify the actions that are indicated for each of the following situations and state the rationale for your actions: a. Output in chest drainage chamber of 500 mL of serous drainage in the last 8 hours b. Continuous bubbling in the water seal chamber c. Patient reports chest pain and dyspnea; absence of breath sounds on the right side of the thorax
4.
A patient is being discharged home on oxygen therapy for the first time. The physician’s prescription is for 2 L of oxygen via nasal cannula. Write a teaching plan for home oxygen therapy to be discussed with the patient before discharge from the hospital.
5.
A patient who had a chest tube inserted 8 hours ago becomes confused and disconnects the chest tube from the drainage system. What immediate actions are indicated in this situation? What nursing assessments and interventions are needed once the immediate situation has been corrected?
REFERENCES AND SELECTED READINGS Books Abraham, I., Bottrell, M., Fulmer, T., & Mezey, M. (1999). Geriatric nursing protocols for best practice. New York: Springer. Cairo, J., & Pilbeam, S. (1999). Respiratory care equipment. St. Louis: Mosby. Clinical practice guidelines. (2000). Dallas, Texas: American Association for Respiratory Care. Doenges, M. E., & Moorhouse, F. (2000). Nurse’s pocket guide. Diagnoses, interventions, and rationales. Philadelphia: F. A. Davis. Dudek, S. G. (2001). Nutrition essentials for nursing practice. Philadelphia: Lippincott. Eliopoulos, C. (2001). Gerontological nursing. Philadelphia: Lippincott Williams & Wilkins. Finkelmeier, B. (2000). Cardiothoracic-surgical nursing. Philadelphia: Lippincott Williams & Wilkins. Hill, N. S. (2000). Long-term mechanical ventilation. New York: Marcel Dekker, Inc. Hurford, W. E. (2000). Airway management. Philadelphia: Lippincott Williams & Wilkins. Kacmarek, R. M. (2000). Advanced respiratory care. Philadelphia: Lippincott Williams & Wilkins. LeFever, J., & Hayes, E. (2000). Pharmacology: A nursing process approach. Philadelphia: W. B. Saunders.
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Lutz, C., & Przytulski, K. (2001). Nutrition and diet therapy. Philadelphia: F. A. Davis. MacIntyre, N. R., & Branson, R. D. (2001). Mechanical ventilation. Philadelphia: W. B. Saunders. McKenry, L., & Salerno, E. (2001). Pharmacology in nursing. St. Louis: Mosby. Mishoe, S. C., & Welch, A. (2001). Critical thinking in respiratory care: A problem-based learning approach. New York: McGraw-Hill, Medical Publishing Division. Ochroch, E. A., & Deutschman, C. S. (2000). Managing the airway in the critically ill patient. Philadelphia: W. B. Saunders. Scanlan, C., Wilkins, R., & Stoller, J. (1999). Fundamentals of respiratory care. St. Louis: Mosby. Wilkins, R. L., Krider, S. J., & Sheldon, R. L. (2000). Clinical assessment in respiratory care. St. Louis: Mosby. Woodrow, P., & Roe, J. (2000). Intensive care nursing: A framework for practice. New York: Routledge. Zang, S., & Allender, J. (1999). Home care of the elderly. Philadelphia: Lippincott Williams & Wilkins.
Journals Asterisks indicate nursing research articles. Avery, S. (2000). Insertion and management of chest drains. Nursing Times, 96(37), 1–6. Baker, S., & Flynn, M. B. (1999). New hope for patients with emphysema: Lung volume reduction surgery. Heart and Lung, 28(6), 455–458. Bar-El, Y., Ross, A., Kablawi, A., & Egenburg, S. (2001). Potentially dangerous negative intrapleural pressures generated by ordinary pleural drainage systems. Chest, 119(2), 511–514. Blackwood, B. (1999). Normal saline instillation with endotracheal suctioning: Primum non nocere (first do no harm). Journal of Advanced Nursing, 29(4), 928–934. Bliss, P., McCoy, R., & Adams, A. (1999). A bench study of comparison of demand oxygen delivery systems and continuous flow oxygen. Respiratory Care, 44(8), 925–929. *Byers, J. F., & Sole, M. L. (2000). Analysis of factors related to the development of ventilator associated pneumonia: Use of existing databases. American Journal of Critical Care, 9(5), 344–351. Carroll, P. (2000). Exploring chest drain options. RN, 63(10), 50–58. Cirino, L., Campos, J., Fernandez, A., Samano, M., Fernandez, P., Filomeno, L. & Jatene, F. (2000). Diagnosis and treatment of mediastinal tumors by thoracoscopy. Chest, 117(6), 1787–1792. Clini, E., Vitacca, M. D., Bianchi, L., Porta, R., & Ambrosino, N. (1999). Long-term tracheostomy in severe COPD patients weaned from mechanical ventilation. Respiratory Care, 44(4), 241–244. Creechan, T. (2000). Combining mechanical ventilation with hospice care in the home: death with dignity. Critical Care Nurse, 20(3), 49–53. Cull, C. (1999). Weaning patients from mechanical ventilation. Professional Nurse, 14(8), 535–538. Cull, C., & Inwood, H. (1999). Extubation in ICU: Enhancing the nursing role. Professional Nurse, 14(9), 535–538. Day, T. (2000). Tracheal suctioning: When, why, and how? Nursing Times, 96(20), 13–15. Doherty, M. J., & Greenstone, M. A. (2000). Noninvasive ventilation in acute exacerbations of chronic obstructive pulmonary disease. Care of the Critically Ill, 116(4), 126–130. Estaban, A., Anzueto, A., Frutos, F., et al. (2002). Characteristics and outcomes in adult patients receiving mechanical ventilation. A 28-day international study. Journal of the American Medical Association, 287(3), 345–355. Ecklund, M. (1999). Successful outcomes for the ventilator-dependent patient. Critical Care Nursing Clinics of North America, 11(2), 249–260. Ferreira, M. M., Brooks, D., Lacasse, Y., & Goldstein, R. S. (2000). Nutritional support for individuals with COPD: A meta-analysis. Chest, 117(3), 672–678. Giannouli, E., Webster, K., Roberts, D., & Younes, M. (1999). Response of ventilator-dependent patients to different levels of pressure support and proportional assist. American Journal of Respiratory and Critical Care Medicine, 159(6), 1716–1725.
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Goodfellow, L. T., & Jones, M. (2002). Bronchial hygiene therapy. American Journal of Nursing, 102(1), 37–43. Hanneman, S. K. (1999). Protocols for practice: Applying research at the bedside. Weaning from short-term mechanical ventilation. Critical Care Nurse, 19(5), 86–89. Hanneman, S. K. (1999). Weaning from short-term mechanical ventilation. Critical Care Nurse, 19(5), 86–89. Happ, M. B. (2000). Preventing treatment interference: The nurse’s role in maintaining technologic devices. Heart & Lung, 29(1), 60–69. Kacmarek, R. M. (2000). Delivery systems for long-term oxygen therapy. State-of-the-art conference on long-term oxygen therapy. Respiratory Care, 45(1), 84–94. *Kinloch, D. (1999). Instillation of normal saline during endotracheal suctioning: Effects on mixed venous oxygen saturation. American Journal of Critical Care, 8(4), 231–240. Kruger, M., & Sandler, A. (1999). Post-thoracotomy pain control. Current Opinion of Anaesthesiology, 12(1), 55–58. Manaligod, J. M., Bendel-Stenzel, E. M., Meyers, P. A., et al. (2000). Variations in end-expiratory pressure during partial liquid ventilation. Chest, 117(1), 184–190. *Mazolewski, P., Turner, J., Baker, M., Kurtz, T., & Little, A. (1999). The impact of nutritional status on the outcome of lung volume reduction surgery. Chest, 116(3), 693–696. McConnell, E. A. (2000). Do’s and don’ts. Suctioning a tracheostomy. Nursing, 30(1), 79–80. National Institutes of Health (2001). National emphysema treatment trial (NETT): Evaluation of lung volume reduction surgery for emphysema. June 20, 2001. http://www.nhlbi.nih.gov/health/prof/lung/nett/ lvrsweb.htm Perkins, L., & Shortall, S. P. (2000). Ventilation without intubation. RN, 63(1), 34–39. *Powers, J., & Bennett, S. J. (1999). Measurement of dyspnea in patients treated with mechanical ventilation. American Journal of Critical Care, 8(4), 254–261. Roviaro, G., Varoli, F., Nucca, O., Vergani, C., & Maciocco, M. (2000). Videothorascopic approach to primary mediastinal pathology. Chest, 117(4), 1179–1183. Schwartz, J. (2000). Role of polyunsaturated fatty acids in lung disease. American Journal of Clinical Nutrition, 71(1), 393–396. Sclafani, J. C. (1999). Clinical perspectives. Home oxygen for adults: selection of appropriate oxygen delivery system. AARC Times, 23(9), 51–54. Seijo, L. M., & Sterman, D. H. (2001). Interventional pulmonology. New England Journal of Medicine, 344(10), 740–749. Serra, A. (2000). Tracheostomy care. Nursing Standard, 14(42), 45–55. Silomon, M., Claus, T., Hower, H., Biedler, A., Larsen, R., & Molter, G. (2000). Interpleural analgesia does not influence post-thoracotomy pain. Anesthesia and Analgesia, 91(1), 44–50.
Smith, L., & McDougall, C. (1999). Removal of chest drains. Nursing Times, 95(12), 24–30. Smith, T., & Matti, A. M. (1999). Respiratory care. Air apparent longterm oxygen therapy. Nursing Times, 95(41), 34–38. *Steuer, J. D., Stone, K. S., Nickel, J., & Steinfeld, Y. (2000). Methodologic issues associated with secretion weight as a dependent variable in research using closed-system suction catheters. Nursing Research, 49(5), 295–299. St. John, R. (1999a). Advances in artificial airway management. Critical Care Nursing Clinics of North America, 11(1), 7–17. St. John, R. E. (1999b). Protocols for practice: applying research at the bedside. Airway management. Critical Care Nurse, 19(4), 79–83. Tasota, F. J., & Dobbin, K. (2000). Weaning your patient from mechanical ventilation. Nursing, 30(10), 41–47. Takezawa, J. (2000). Hyperbaric oxygen therapy. Critical Care Alert, 8(8), 88–93. Tamburri, L. M. (2000). Care of the patient with a tracheostomy. Orthopaedic Nursing, 19(2), 49–60. Tobin, M. J. (2001). Advances in mechanical ventilation. New England Journal of Medicine, 344(26), 1986–1996. Tonelli, M. R. (1999). Withdrawing mechanical ventilation: Conflicts and consensus. Respiratory Care, 44(11), 1383–1387. Truesdell, S. (2000). Helping patients with COPD manage episodes of acute shortness of breath. MedSurg Nursing, 9(4), 178–182. Valenzuela, R., & Rosen, D. (1999). Topical lidocaine-prilocaine cream (EMLA) for thoracostomy tube removal. Anesthesia and Analgesia, 88(1), 1107–1108. Wilmoth, D. (1999). New strategies for mechanical ventilation: Lung protective ventilation. Critical Care Nursing Clinics of North America, 11(4), 447–454. Woodruff, D. W. (1999). How to ward off complications of mechanical ventilation. Nursing, 29(11), 34–39. Zevola, D. R., & Maier, B. (1999). Improving the care of cardiothoracic surgery patients through advanced nursing skills. Critical Care Nurse, 19(1), 34–36.
RESOURCES AND WEBSITES American Association for Respiratory Care, 11030 Ables Lane, Dallas, TX 75229; (972) 243-2272; http://www.aarc.org. American Lung Association, 1740 Broadway, New York, NY 10019; (212) 315-8700, (800) LUNG-USA; http://www.lungusa.org. American Thoracic Society, 1740 Broadway, New York, NY 10019; (212) 315-8700; http://www.thoracic.org. National Heart, Lung and Blood Institute, National Institutes of Health, 9000 Rockville Pike, Bldg 31, Rm 5A52, Bethesda, MD 20892; (301) 496-5166 or (301) 496-4236; http://www.nhlbi.nih.gov.
Chapter
26 ●
Assessment of Cardiovascular Function
LEARNING OBJECTIVES
●
On completion of this chapter, the learner will be able to: 1. Explain cardiac physiology in relation to cardiac anatomy and the 2. 3. 4.
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conduction system of the heart. Incorporate assessment of functional health patterns and cardiac risk factors into the health history and physical assessment of the patient with cardiac conditions. Identify the clinical significance and related nursing implications of the various tests and procedures used for diagnostic assessment of cardiac function. Compare central venous pressure monitoring, pulmonary artery pressure monitoring, and systemic intra-arterial monitoring with regard to clinical usefulness and significance, possible complications, and nursing responsibilities.
Chapter 26
T
hroughout the continuum of care, whether in a home, hospital, or rehabilitation setting, all patients with cardiovascular disease (disorders of the heart and major blood vessels; CVD) require similar assessments. Key components of the cardiovascular assessment include obtaining a health history, performing a physical assessment, and monitoring a variety of laboratory and diagnostic test results. An accurate and timely assessment of cardiovascular function provides the data necessary to identify nursing diagnoses, formulate a plan of care, and evaluate the response of the patient to the care provided. Essential to the development of these assessment skills is an understanding of the structure and function of the heart in health and in disease.
Anatomic and Physiologic Overview The heart is a hollow, muscular organ located in the center of the thorax, where it occupies the space between the lungs (mediastinum) and rests on the diaphragm. It weighs approximately 300 g (10.6 oz), although heart weight and size are influenced by age, gender, body weight, extent of physical exercise and conditioning, and heart disease. The heart pumps blood to the tissues, supplying them with oxygen and other nutrients. The pumping action of the heart is accomplished by the rhythmic contraction and relaxation of its muscular wall. During systole (contraction of the muscle), the chambers of the heart become smaller as the blood is ejected. During diastole (relaxation of the muscle), the heart chambers fill with blood in preparation for the subsequent ejection. A normal resting adult heart beats approximately 60 to 80 times per minute. Each ventricle ejects approxi-
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mately 70 mL of blood per beat and has an output of approximately 5 L per minute.
ANATOMY OF THE HEART The heart is composed of three layers (Fig. 26-1). The inner layer, or endocardium, consists of endothelial tissue and lines the inside of the heart and valves. The middle layer, or myocardium, is made up of muscle fibers and is responsible for the pumping action. The exterior layer of the heart is called the epicardium. The heart is encased in a thin, fibrous sac called the pericardium, which is composed of two layers. Adhering to the epicardium is the visceral pericardium. Enveloping the visceral pericardium is the parietal pericardium, a tough fibrous tissue that attaches to the great vessels, diaphragm, sternum, and vertebral column and supports the heart in the mediastinum. The space between these two layers (pericardial space) is filled with about 30 mL of fluid, which lubricates the surface of the heart and reduces friction during systole.
Heart Chambers The four chambers of the heart constitute the right- and leftsided pumping systems. The right side of the heart, made up of the right atrium and right ventricle, distributes venous blood (deoxygenated blood) to the lungs via the pulmonary artery (pulmonary circulation) for oxygenation. The right atrium receives blood returning from the superior vena cava (head, neck, and upper extremities), inferior vena cava (trunk and lower extremities), and coronary sinus (coronary circulation). The left
Glossary afterload: the amount of resistance to ejection of blood from the ventricle apical impulse (also called point of maximum impulse [PMI]): impulse normally palpated at the fifth intercostal space, left midclavicular line; caused by contraction of the left ventricle baroreceptors: nerve fibers located in the aortic arch and carotid arteries that are responsible for reflex control of the blood pressure cardiac catheterization: an invasive procedure used to measure cardiac chamber pressures and assess patency of the coronary arteries cardiac conduction system: specialized heart cells strategically located throughout the heart that are responsible for methodically generating and coordinating the transmission of electrical impulses to the myocardial cells cardiac output: amount of blood pumped by each ventricle in liters per minute; normal cardiac output is 5 L per minute in the resting adult heart cardiac stress test: a test used to evaluate the functioning of the heart during a period of increased oxygen demand contractility: ability of the cardiac muscle to shorten in response to an electrical impulse
depolarization: electrical activation of a cell caused by the influx of sodium into the cell while potassium exits the cell diastole: period of ventricular relaxation resulting in ventricular filling ejection fraction: percentage of the enddiastolic blood volume ejected from the ventricle with each heartbeat hemodynamic monitoring: use of monitoring devices to measure cardiovascular function hypertension: blood pressure greater than 140/90 mm Hg hypotension: a decrease in blood pressure to less than 100/60 mm Hg international normalized ratio (INR): a standard method for reporting prothrombin levels, eliminating the variation in test results from laboratory to laboratory murmurs: sounds created by abnormal, turbulent flow of blood in the heart myocardial ischemia: condition in which heart muscle cells receive less oxygen than needed myocardium: muscle layer of the heart responsible for the pumping action of the heart normal heart sounds: sounds produced when the valves close; normal heart sounds are S1 (atrioventricular valves) and S2 (semilunar valves)
postural (orthostatic) hypotension: a significant drop in blood pressure (usually 10 mm Hg systolic or more) after an upright posture is assumed preload: degree of stretch of the cardiac muscle fibers at the end of diastole pulmonary vascular resistance: resistance to right ventricle ejection of blood radioisotopes: unstable atoms that emit small amounts of energy in the form of gamma rays; used in cardiac nuclear medicine studies repolarization: return of the cell to resting state, caused by reentry of potassium into the cell while sodium exits the cell sinoatrial (SA) node: primary pacemaker of the heart, located in the right atrium stroke volume: amount of blood ejected from the ventricle per heartbeat; normal stroke volume is 70 mL in the resting heart systemic vascular resistance: resistance to left ventricle ejection systole: period of ventricular contraction resulting in ejection of blood from the ventricles into the pulmonary artery and aorta telemetry: the process of continuous electrocardiographic monitoring by the transmission of radiowaves from a battery-operated transmitter worn by the patient venodilating agent: medication causing dilation of veins
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Physiology/Pathophysiology
Superior vena cava
Aortic arch Right pulmonary artery
Left pulmonary artery
Pulmonic valve Interatrial septum
Pulmonary veins
Pulmonary veins
Left atrium Aortic valve
Right atrium
Mitral valve Chordae tendineae
Tricuspid valve
Left ventricle Right ventricle
Papillary muscles
Inferior vena cava Interventricular septum
Papillary muscles
Descending aorta
Visceral pericardium Pericardial Epicardium space Endocardium
Unoxygenated blood Myocardium Oxygenated blood Parietal pericardium
side of the heart, composed of the left atrium and left ventricle, distributes oxygenated blood to the remainder of the body via the aorta (systemic circulation). The left atrium receives oxygenated blood from the pulmonary circulation via the pulmonary veins. The relationships of the four heart chambers are shown in Figure 26-1. The varying thicknesses of the atrial and ventricular walls relate to the workload required by each chamber. The atria are thin-walled because blood returning to these chambers generates low pressures. In contrast, the ventricular walls are thicker because they generate greater pressures during systole. The right ventricle contracts against low pulmonary vascular pressure and has thinner walls than the left ventricle. The left ventricle, with walls two-and-a-half times more muscular than those of the right ventricle, contracts against high systemic pressure. Because the heart lies in a rotated position within the chest cavity, the right ventricle lies anteriorly (just beneath the sternum) and the left ventricle is situated posteriorly. The left ventricle is responsible for the apex beat or the point of maximum impulse (PMI), which is normally palpable in the left midclavicular line of the chest wall at the fifth intercostal space.
FIGURE 26-1 Structure of the heart. Arrows show course of blood flow through the heart chambers.
Heart Valves The four valves in the heart permit blood to flow in only one direction. The valves, which are composed of thin leaflets of fibrous tissue, open and close in response to the movement of blood and pressure changes within the chambers. There are two types of valves: atrioventricular and semilunar. ATRIOVENTRICULAR VALVES The valves that separate the atria from the ventricles are termed atrioventricular valves. The tricuspid valve, so named because it is composed of three cusps or leaflets, separates the right atrium from the right ventricle. The mitral, or bicuspid (two cusps) valve, lies between the left atrium and the left ventricle (see Fig. 26-1). Normally, when the ventricles contract, ventricular pressure rises, closing the atrioventricular valve leaflets. Two additional structures, the papillary muscles and the chordae tendineae, maintain valve closure. The papillary muscles, located on the sides of the ventricular walls, are connected to the valve leaflets by thin fibrous bands called chordae tendineae. During systole, contraction of the papillary muscles causes the chordae tendineae to become taut, keeping the valve leaflets approximated and closed.
Chapter 26 SEMILUNAR VALVES The two semilunar valves are composed of three half-moon-like leaflets. The valve between the right ventricle and the pulmonary artery is called the pulmonic valve; the valve between the left ventricle and the aorta is called the aortic valve.
Coronary Arteries The left and right coronary arteries and their branches (Fig. 26-2) supply arterial blood to the heart. These arteries originate from the aorta just above the aortic valve leaflets. The heart has large metabolic requirements, extracting approximately 70% to 80% of the oxygen delivered (other organs consume, on average, 25%). Unlike other arteries, the coronary arteries are perfused during diastole. An increase in heart rate shortens diastole and can decrease myocardial perfusion. Patients, particularly those with coronary artery disease (CAD), can develop myocardial ischemia (inadequate oxygen supply) when the heart rate accelerates. The left coronary artery has three branches. The artery from the point of origin to the first major branch is called the left main coronary artery. Two bifurcations arise off the left main coronary artery. These are the left anterior descending artery, which courses down the anterior wall of the heart, and the circumflex artery, which circles around to the lateral left wall of the heart. The right side of the heart is supplied by the right coronary artery, which progresses around to the bottom or inferior wall of the heart. The posterior wall of the heart receives its blood supply by an additional branch from the right coronary artery called the posterior descending artery. Superficial to the coronary arteries are the coronary veins. Venous blood from these veins returns to the heart primarily through the coronary sinus, which is located posteriorly in the right atrium.
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Cardiac Muscle The myocardium is composed of specialized muscle tissue. Microscopically, myocardial muscle resembles striated (skeletal) muscle, which is under conscious control. Functionally, however, myocardial muscle resembles smooth muscle because its contraction is involuntary. The myocardial muscle fibers are arranged in an interconnected manner (called a syncytium) that allows for coordinated myocardial contraction and relaxation. The sequential pattern of contraction and relaxation of individual muscle fibers ensures the rhythmic behavior of the myocardium as a whole and enables it to function as an effective pump.
FUNCTION OF THE HEART: CONDUCTION SYSTEM The specialized heart cells of the cardiac conduction system methodically generate and coordinate the transmission of electrical impulses to the myocardial cells. The result is sequential atrioventricular contraction, which provides for the most effective flow of blood, thereby optimizing cardiac output. Three physiologic characteristics of the cardiac conduction cells account for this coordination: Automaticity: ability to initiate an electrical impulse Excitability: ability to respond to an electrical impulse Conductivity: ability to transmit an electrical impulse from one cell to another The sinoatrial (SA) node, referred to as the primary pacemaker of the heart, is located at the junction of the superior vena cava and the right atrium (Fig. 26-3). The SA node in a normal resting heart has an inherent firing rate of 60 to 100 impulses per minute, but the rate can change in response to the metabolic demands of the body. The electrical impulses initiated by the SA node are conducted along the myocardial cells of the atria via specialized tracts called internodal pathways. The impulses cause electrical stimulation
Aortic arch
AV node
SA node Left main coronary artery
Left bundle branch
Circumflex coronary artery Right coronary artery Posterior descending coronary artery
FIGURE 26-2
Left anterior descending coronary artery
Coronary arteries (red vessels) arise from the aorta and encircle the heart. Coronary veins are shown in blue.
Bundle of His
Purkinje fibers Right bundle branch
FIGURE 26-3 sinoatrial.
The cardiac conduction system. AV, atrioventricular; SA,
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and subsequent contraction of the atria. The impulses are then conducted to the atrioventricular (AV) node. The AV node (located in the right atrial wall near the tricuspid valve) consists of another group of specialized muscle cells similar to those of the SA node. The AV node coordinates the incoming electrical impulses from the atria and, after a slight delay (allowing the atria time to contract and complete ventricular filling), relays the impulse to the ventricles. This impulse is then conducted through a bundle of specialized conduction cells (bundle of His) that travel in the septum separating the left and right ventricles. The bundle of His divides into the right bundle branch (conducting impulses to the right ventricle) and the left bundle branch (conducting impulses to the left ventricle). To transmit impulses to the largest chamber of the heart, the left bundle branch bifurcates into the left anterior and left posterior bundle branches. Impulses travel through the bundle branches to reach the terminal point in the conduction system, called the Purkinje fibers. This is the point at which the myocardial cells are stimulated, causing ventricular contraction. The heart rate is determined by the myocardial cells with the fastest inherent firing rate. Under normal circumstances, the SA node has the highest inherent rate, the AV node has the secondhighest inherent rate (40 to 60 impulses per minute), and the ventricular pacemaker sites have the lowest inherent rate (30 to 40 impulses per minute). If the SA node malfunctions, the AV node generally takes over the pacemaker function of the heart at its inherently lower rate. Should both the SA and the AV nodes fail in their pacemaker function, a pacemaker site in the ventricle will fire at its inherent bradycardic rate of 30 to 40 impulses per minute.
Physiology of Cardiac Conduction Cardiac electrical activity is the result of the movement of ions (charged particles such as sodium, potassium, and calcium) across the cell membrane. The electrical changes recorded within a single cell result in what is known as the cardiac action potential (Fig. 26-4). In the resting state, cardiac muscle cells are polarized, which means an electrical difference exists between the negatively charged inside and the positively charged outside of the cell membrane.
As soon as an electrical impulse is initiated, cell membrane permeability changes and sodium moves rapidly into the cell, while potassium exits the cell. This ionic exchange begins depolarization (electrical activation of the cell), converting the internal charge of the cell to a positive one (see Fig. 26-4). Contraction of the myocardium follows depolarization. The interaction between changes in membrane voltage and muscle contraction is called electromechanical coupling. As one cardiac muscle cell is depolarized, it acts as a stimulus to its neighboring cell, causing it to depolarize. Sufficient depolarization of a single specialized conduction system cell results in depolarization and contraction of the entire myocardium. Repolarization (return of the cell to its resting state) occurs as the cell returns to its baseline or resting state; this corresponds to relaxation of myocardial muscle. After the rapid influx of sodium into the cell during depolarization, the permeability of the cell membrane to calcium is changed. Calcium enters the cell and is released from intracellular calcium stores. The increase in calcium, which occurs during the plateau phase of repolarization, is much slower than that of sodium and continues for a longer period. Cardiac muscle, unlike skeletal or smooth muscle, has a prolonged refractory period during which it cannot be restimulated to contract. There are two phases of the refractory period, referred to as the absolute refractory period and the relative refractory period. The absolute refractory period is the time during which the heart cannot be restimulated to contract regardless of the strength of the electrical stimulus. This period corresponds with depolarization and the early part of repolarization. During the latter part of repolarization, however, if the electrical stimulus is stronger than normal, the myocardium can be stimulated to contract. This short period at the end of repolarization is called the relative refractory period. Refractoriness protects the heart from sustained contraction (tetany), which would result in sudden cardiac death. Normal electromechanical coupling and contraction of the heart depend on the composition of the interstitial fluid surrounding the heart muscle cells. In turn, the composition of this fluid is influenced by the composition of the blood. A change in serum calcium concentration may alter the contraction of the heart muscle fibers. A change in serum potassium concentration is also important, because potassium affects the normal electrical voltage of the cell.
Cardiac Hemodynamics PHASE 1 Rapid repolarization PHASE 2 Plateau Potential (mV)
PHASE 0 Rapid depolarization
PHASE 3 Final repolarization PHASE 4 Resting
Cell membrane
FIGURE 26-4
Cardiac action potential. The arrows indicate the approximate time and direction of movement of each ion influencing membrane potential. Ca++ movement out of the cell is not well defined but is thought to occur during Phase 4.
An important determinant of blood flow in the cardiovascular system is the principle that fluid flows from a region of higher pressure to one of lower pressure. The pressures responsible for blood flow in the normal circulation are generated during systole and diastole. Figure 26-5 depicts the pressure differences in the great vessels and in the four chambers of the heart during systole and diastole. CARDIAC CYCLE Beginning with systole, the pressure inside the ventricles rapidly rises, forcing the atrioventricular valves to close. As a result, blood ceases to flow from the atria into the ventricles and regurgitation (backflow) of blood into the atria is prevented. The rapid rise of pressure inside the right and left ventricles forces the pulmonic and aortic valves to open, and blood is ejected into the pulmonary artery and aorta, respectively. The exit of blood is at first rapid;
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Physiology/Pathophysiology
Superior vena cava
8–10 Right pulmonary artery
Left pulmonary artery 15–25 8–15
Pulmonic valve Pulmonary veins
Aortic arch
110–130 70–80
Pulmonary veins
0–8
Left atrium 4–12
Aortic valve Mitral valve
Right atrium
Chordae tendineae
Tricuspid valve
Left ventricle 110–130 4–12
Right ventricle Inferior vena cava
Papillary muscles
15–25 0–8 Interventricular septum
FIGURE 26-5
Great vessel and chamber pressures. Pressures are identified in millimeters of mercury (mm Hg) as mean pressure or systolic over diastolic pressure.
Papillary muscles
then, as the pressure in each ventricle and its corresponding artery equalizes, the flow of blood gradually decreases. At the end of systole, pressure within the right and left ventricles rapidly decreases. This lowers pulmonary artery and aortic pressure, causing closure of the semilunar valves. These events mark the onset of diastole. During diastole, when the ventricles are relaxed and the atrioventricular valves are open, blood returning from the veins flows into the atria and then into the ventricles. Toward the end of this diastolic period, the atrial muscles contract in response to an electrical impulse initiated by the SA node (atrial systole). The resultant contraction raises the pressure inside the atria, ejecting blood into the ventricles. Atrial systole augments ventricular blood volume by 15% to 25% and is sometimes referred to as the “atrial kick.” At this point, ventricular systole begins in response to propagation of the electrical impulse that began in the SA node some milliseconds previously. The following section reviews the chamber pressures generated during systole and diastole. Chamber Pressures. In the right side of the heart, the pressure generated during ventricular systole (15 to 25 mm Hg) exceeds the pulmonary artery diastolic pressure (8 to 15 mm Hg), and blood is ejected into the pulmonary circulation. During diastole, venous blood flows into the atrium because pressure in the superior and inferior vena cava (8 to 10 mm Hg) is higher than that in the atrium. Blood flows through the open tricuspid valve and
Descending aorta
into the right ventricle until the two right chamber pressures equalize (0 to 8 mm Hg). In the left side of the heart, similar events occur, although higher pressures are generated. As pressure mounts in the left ventricle during systole (110 to 130 mm Hg), resting aortic pressure (80 mm Hg) is exceeded and blood is ejected into the aorta. During left ventricular ejection, the resultant aortic pressure (110 to 130 mm Hg) forces blood progressively through the arteries. Forward blood flow into the aorta ceases as the ventricle relaxes and pressure drops. During diastole, oxygenated blood returning from the pulmonary circulation via the four pulmonary veins flows into the atrium, where pressure remains low. Blood readily flows into the left ventricle because ventricular pressure is also low. At the end of diastole, pressure in the atrium and ventricle equilibrates (4 to 12 mm Hg). Figure 26-5 depicts the systolic and diastolic pressures in the four chambers of the heart. Pressure Measurement. Chamber pressures are measured with the use of special monitoring catheters and equipment. This technique is called hemodynamic monitoring. Nurses caring for critically ill patients must have a sophisticated working knowledge of normal chamber pressures and the hemodynamic changes that occur during serious illnesses. The data obtained from hemodynamic monitoring assist with the diagnosis and management of pathophysiologic conditions affecting critically ill patients. Hemodynamic monitoring is covered in more detail at the end of this chapter.
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Cardiac Output Cardiac output is the amount of blood pumped by each ventricle during a given period. The cardiac output in a resting adult is about 5 L per minute but varies greatly depending on the metabolic needs of the body. Cardiac output is computed by multiplying the stroke volume by the heart rate. Stroke volume is the amount of blood ejected per heartbeat. The average resting stroke volume is about 70 mL, and the heart rate is 60 to 80 beats per minute (bpm). Cardiac output can be affected by changes in either stroke volume or heart rate. CONTROL OF HEART RATE Cardiac output must be responsive to changes in the metabolic demands of the tissues. For example, during exercise the total cardiac output may increase fourfold, to 20 L per minute. This increase is normally accomplished by approximate doubling of both the heart rate and the stroke volume. Changes in heart rate are accomplished by reflex controls mediated by the autonomic nervous system, including its sympathetic and parasympathetic divisions. The parasympathetic impulses, which travel to the heart through the vagus nerve, can slow the cardiac rate, whereas sympathetic impulses increase it. These effects on heart rate result from action on the SA node, to either decrease or increase its inherent rate. The balance between these two reflex control systems normally determines the heart rate. The heart rate is stimulated also by an increased level of circulating catecholamines (secreted by the adrenal gland) and by excess thyroid hormone, which produces a catecholamine-like effect. Heart rate is also affected by central nervous system and baroreceptor activity. Baroreceptors are specialized nerve cells located in the aortic arch and in both right and left internal carotid arteries (at the point of bifurcation from the common carotid arteries). The baroreceptors are sensitive to changes in blood pressure (BP). During elevations in BP (hypertension), these cells increase their rate of discharge, transmitting impulses to the medulla. This initiates parasympathetic activity and inhibits sympathetic response, lowering the heart rate and the BP. The opposite is true during hypotension (low BP). Hypotension results in less baroreceptor stimulation, which prompts a decrease in parasympathetic inhibitory activity in the SA node, allowing for enhanced sympathetic activity. The resultant vasoconstriction and increased heart rate elevate the BP. CONTROL OF STROKE VOLUME Stroke volume is primarily determined by three factors: preload, afterload, and contractility. Preload is the term used to describe the degree of stretch of the cardiac muscle fibers at the end of diastole. The end of diastole is the period when filling volume in the ventricles is the highest and the degree of stretch on the muscle fibers is the greatest. The volume of blood within the ventricle at the end of diastole determines preload. Preload has a direct effect on stroke volume. As the volume of blood returning to the heart increases, muscle fiber stretch also increases (increased preload), resulting in stronger contraction and a greater stroke volume. This relationship, called the Frank-Starling law of the heart (or sometimes the Starling law of the heart), is maintained until the physiologic limit of the muscle is reached. The Frank-Starling law is based on the fact that, within limits, the greater the initial length or stretch of the cardiac muscle cells (sarcomeres), the greater the degree of shortening that occurs. This result is caused by increased interaction between the
thick and thin filaments within the cardiac muscle cells. Preload is decreased by a reduction in the volume of blood returning to the ventricles. Diuresis, venodilating agents (eg, nitrates), and loss of blood or body fluids from excessive diaphoresis, vomiting, or diarrhea reduce preload. Preload is increased by increasing the return of circulating blood volume to the ventricles. Controlling the loss of blood or body fluids and replacing fluids (ie, blood transfusions and intravenous fluid administration) are examples of ways to increase preload. The second determinant of stroke volume is afterload, the amount of resistance to ejection of blood from the ventricle. The resistance of the systemic BP to left ventricular ejection is called systemic vascular resistance. The resistance of the pulmonary BP to right ventricular ejection is called pulmonary vascular resistance. There is an inverse relationship between afterload and stroke volume. For example, afterload is increased by arterial vasoconstriction, which leads to decreased stroke volume. The opposite is true with arterial vasodilation: afterload is reduced because there is less resistance to ejection, and stroke volume increases. Contractility is a term used to denote the force generated by the contracting myocardium under any given condition. Contractility is enhanced by circulating catecholamines, sympathetic neuronal activity, and certain medications (eg, digoxin, intravenous dopamine or dobutamine). Increased contractility results in increased stroke volume. Contractility is depressed by hypoxemia, acidosis, and certain medications (eg, beta-adrenergic blocking agents such as atenolol [Tenormin]). The heart can achieve a greatly increased stroke volume (eg, during exercise) by increasing preload (through increased venous return), increasing contractility (through sympathetic nervous system discharge), and decreasing afterload (through peripheral vasodilation with decreased aortic pressure). The percentage of the end-diastolic volume that is ejected with each stroke is called the ejection fraction. With each stroke, about 42% (right ventricle) to 50% (left ventricle) or more of the end-diastolic volume is ejected by the normal heart. The ejection fraction can be used as an index of myocardial contractility: the ejection fraction decreases if contractility is depressed. Gerontologic Considerations Changes in cardiac structure and function are clearly observable in the older heart. To understand the changes specifically related to aging, it is helpful to distinguish the normal aging process from changes related to CVD. The anatomic and functional changes in the aging heart are listed in Table 26-1. Studies show that the normal aging heart can produce adequate cardiac output under ordinary circumstances but may have a limited ability to respond to situations that cause physical or emotional stress. In an elderly person who is less active, the left ventricle may become smaller (atrophy) as a consequence of physical deconditioning. Aging also results in decreased elasticity and widening of the aorta, thickening and rigidity of the cardiac valves, and increased connective tissue in the SA and AV nodes and bundle branches. These changes lead to decreased myocardial contractility, increased left ventricular ejection time (prolonged systole), and delayed conduction. Therefore, stressful physical and emotional conditions, especially those that occur suddenly, may have adverse effects on the aged person. The heart cannot respond to such conditions with an adequate rate increase and needs more time to return to a normal resting rate after even a minimal increase in heart rate. In some patients, the added stress may precipitate heart failure (HF).
Chapter 26
Table 26-1
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• Age-Related Changes of the Cardiac System
CARDIOVASCULAR SYSTEM
STRUCTURAL CHANGES
FUNCTIONAL CHANGES
HISTORY AND PHYSICAL FINDINGS
Atria
↑ Size of left atrium Thickening of the endocardium Endocardial fibrosis Myocardial thickening (hypertrophy) Infiltration of fat into myocardium
↑ Atrial irritability
Thickening and rigidity of AV valves Calcification of aortic valve Connective tissue collects in SA node, AV node, and bundle branches ↓ Number SA node cells ↓ Number AV, bundle of His, right and left bundle branch cells ↓ Response to beta-adrenergic stimulation
Abnormal blood flow across valves during cardiac cycle
Irregular heart rhythm from atrial dysrhythmias Fatigue ↓ Exercise tolerance Signs and symptoms of HF or ventricular dysrhythmias Point of maximal impulse palpated lateral to the midclavicular line ↓ Intensity S1, S2; split S2 S4 may be present Murmurs may be present Thrill may be palpated if significant murmur is present Bradycardia Heart block ECG changes consistent with slowed conduction (↑ PR interval, widened QRS complex)
Left ventricle
Valves
Conduction system
Sympathetic nervous system
Aorta and arteries
Baroreceptor response
Stiffening of vasculature ↓ Elasticity and widening of aorta Elongation of aorta, displacing the brachiocephalic artery upward ↓ Sensitivity of baroreceptors in the carotid artery and aorta to transient episodes of hypertension and hypotension
Left ventricle stiff and less compliant Progressive decline in cardiac output ↑ Risk for ventricular dysrhythmias Prolonged systole
Slower SA node rate of impulse discharge Slowed conduction across AV node and ventricular conduction system ↓ Adaptive response to exercise: contractility and heart rate slower to respond to exercise demands Heart rate takes more time to return to baseline Left ventricular hypertrophy
Baroreceptors unable to regulate heart rate and vascular tone, causing slow response to postural changes in body position
Fatigue Diminished exercise tolerance ↓ Ability to respond to stress
Progressive increase in systolic BP; slight ↑ in diastolic BP Widening pulse pressure Pulsation visible above right clavicle Postural blood pressure changes and reports feeling dizzy, fainting when moving from lying to sitting or standing position
AV, atrioventricular; BP, blood pressure; CHF, congestive heart failure; ECG, electrocardiographic; SA, sinoatrial.
GENDER DIFFERENCES IN CARDIAC STRUCTURE AND FUNCTION Compared with a man’s heart, a woman’s heart tends to be smaller. It weighs less and has smaller coronary arteries. These structural differences have significant implications. Because the coronary arteries of a woman are smaller, they occlude from atherosclerosis more easily, making procedures such as cardiac catheterization and angioplasty technically more difficult, with a higher incidence of postprocedure complications. In addition, the resting rate, stroke volume, and ejection fraction of a woman’s heart are higher than those of a man’s, and the conduction time of an electrical impulse coursing from the SA node through the AV node to the Purkinje fibers is briefer. Another significant difference between the genders is the physiologic effects of estrogen on the cardiovascular system. Two important effects of estrogen, regulation of vasomotor tone and of response to vascular injury, may be the mechanisms that protect women against the development of atherosclerosis. An additional, potentially beneficial effect of estrogen is its action on the
liver, which results in improved lipid profiles. On the other hand, less favorable effects of estrogen include an increase in coagulation proteins and a decrease in fibrinolytic protein, which enhance the risk of thrombus formation. Progesterone also has vascular effects, but its role in the development of CVD is unclear at this time. Beneficial effects of estrogen disappear after menopause, as evidenced by the increased incidence of CVD in this population. However, because of health risks associated with hormone replacement therapy, the American Heart Association does not recommend its use as a primary or secondary prevention intervention for CVD (Mosca et al., 2001; Roussouw et al., 2002).
Assessment The severity of the patient’s symptoms, the practice setting of the nurse, and the purpose of the assessment are factors that need to be considered when determining the frequency and extent of nursing assessment required. The assessment of the acutely ill cardiac patient will be different from that of a patient with stable or chronic cardiac conditions. For example, the assessment per-
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formed by an emergency department nurse caring for a patient who is experiencing an acute myocardial infarction (MI) must be very focused and must be performed rapidly. The nurse must assess the patient for complications associated with the MI, screen the patient for contraindications to coronary artery reperfusion strategies including thrombolytic therapy or primary percutaneous transluminal coronary angioplasty (PTCA), and evaluate the patient’s response to medical and nursing interventions. For this patient, the health history, physical assessment, and important nursing interventions (eg, cardiac monitoring, administration of intravenous medications) are performed simultaneously.
HEALTH HISTORY AND CLINICAL MANIFESTATIONS For the patient experiencing an acute MI, the nurse obtains the health history using a few specific questions about the onset and severity of chest discomfort, associated symptoms, current medications, and allergies. At the same time, the nurse observes the
patient’s general appearance and evaluates hemodynamic status (heart rate and rhythm, BP). Once the condition of the patient stabilizes, a more extensive history can be obtained. With stable patients, a complete health history is obtained during the initial contact. Often, it is helpful to have the patient’s spouse or partner available during the health history interview. Initially, demographic information regarding age, gender, and ethnic origin is obtained. The family history, as well as the physical examination, should include assessment for genetic abnormalities associated with cardiovascular disorders (see Genetics in Nursing Practice box). Height, current weight, and usual weight (if there has been a recent weight loss or gain) are established. During the interview, the nurse conveys sensitivity to the cultural background and religious practices of the patient. This removes barriers to communication that may result if the interview is based only on the nurse’s personal frame of reference. Patients from different cultural and ethnic groups may have different ways of describing symptoms such as pain and may engage in different health practices before seeking formal medical attention.
NURSING RESEARCH PROFILE 26-1
Racial Differences in Coronary Artery Disease: Symptoms and Seeking Care Richards, S. B., Funk, M., & Milner, K. A. (2000). Differences between blacks and whites with coronary heart disease in initial symptoms and delay in seeking care. American Journal of Critical Care, 9, 237–244.
Purpose Mortality rates due to coronary artery disease (CAD) are higher in African American men (7%) and African American women (35%) than in their Caucasian counterparts. Recent findings suggest that African Americans may delay longer than Caucasians in seeking emergency care and commonly have atypical symptom presentation. The purpose of this study was to explore differences between African Americans and Caucasians in both manifestations of symptoms of CAD and delay in seeking treatment by answering the following research questions: • Do African Americans and Caucasians differ in their manifestation of symptoms of CAD? • Among patients with confirmed CAD, do African Americans and Caucasians differ in the elapsed time between the onset of symptoms and arrival at the emergency department? Study Sample and Design This study, part of a larger study investigating aspects of CAD presentation, is the first of its kind to use a prospective, observational design. One member of the team of nurse researchers unobtrusively observed patients in the emergency department as they described their symptoms to the clinician. The sample consisted of African Americans and Caucasians drawn from a total of 545 patients who were recruited from the emergency department of an 810-bed university teaching hospital. Patients with one or more typical or atypical symptoms of CAD, who met agespecific inclusion criteria based on the Framingham Heart Study, were enrolled. Electrocardiographic and cardiac enzyme criteria were used to confirm the diagnosis of angina or myocardial infarction. Findings Of the 231 patients with CAD, 40 (17%) were African American and 191 (82.7%) were Caucasian. The majority of the patients were male (58%). Ages ranged from 31 to 91 years. There were statistically sig-
nificant differences in age and cardiac risk factors between the groups of African Americans and Caucasians. The mean age was significantly younger in African Americans than in Caucasians. Caucasians were more likely than African Americans to have hyperlipidemia, and African Americans were more likely than Caucasians to have hypertension. Among all patients, shortness of breath, not chest pain, was the most common symptom (39.8%). Next, in descending order, were substernal chest pain (34%) and arm pain (27.2%). Both research questions were answered affirmatively. African Americans were more likely than Caucasians to have atypical presentation of acute CAD symptoms. These patients, the majority of whom were female (62.5%), were about three times more likely than Caucasians to experience shortness of breath as the predominant symptom and two times more likely to complain of left-sided chest pain. African Americans were found to have a median delay time of 11 hours, while Caucasians delayed 5 hours. This difference was significant ( p = .05), demonstrating a trend toward longer delays by African Americans compared with Caucasians. Nineteen people in this study delayed 72 hours or longer before seeking treatment. Nursing Implications Studies such as this one contribute to the growing body of evidence showing that there are racial differences in the presentation of acute CAD. Nurses and other health care professionals need to be aware that “atypical” symptoms of angina and myocardial infarction, such as shortness of breath or left-sided chest pain, are common, especially among African Americans. Any patient with shortness of breath or left-sided chest pain should be assessed for other symptoms of CAD. Nurses should consult with nurse practitioners or physicians regarding diagnostic studies for CAD for any patient experiencing one or both of these symptoms. Nurses can teach colleagues and the lay public about shortness of breath, left-sided chest pain, and other symptoms of CAD and instruct them on how to access the emergency medical system if any of these symptoms are experienced.
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GENETICS IN NURSING PRACTICE—Cardiovascular Disorders Several cardiovascular disorders are associated with genetic abnormalities. Some examples are: • Familial hypercholesterolemia • Hypertrophic cardiomyopathy • Long QT syndrome (LQTS) • Hereditary hemochromatosis • Elevated homocystine levels NURSING ASSESSMENTS FAMILY HISTORY ASSESSMENT
• Assess all patients with cardiovascular symptoms for coronary artery disease, regardless of age (early-onset CAD occurs).
• Assess family history of sudden death in persons who may or • • •
may not have been diagnosed with coronary disease (especially of early onset). Ask about sudden death in a previously asymptomatic child, adolescent, or adult. Ask about other family members with biochemical or neuromuscular conditions (eg, hemochromatosis or muscular dystrophy). Assess whether DNA mutation or other genetic testing has been performed on an affected family member
ASSESSMENT
• Assess for signs and symptoms of hyperlipidemias (xanthomas,
MANAGEMENT ISSUES SPECIFIC TO GENETICS
• If indicated, refer for further genetic counseling and evalua-
• •
tion so that the family can discuss inheritance, risk to other family members, availability of genetic testing, and genebased interventions Offer appropriate genetic information and resources (eg, Genetic Alliance website, American Heart Association, Muscular Dystrophy Association) Provide support to families newly diagnosed with geneticrelated cardiovascular disease
GENETICS RESOURCES Genetic Alliance—a directory of support groups for patients and families with genetic conditions; http://www.geneticalliance. org. Gene Clinics—a listing of common genetic disorders with up-todate clinical summaries, genetic counseling, and testing information; http://www.geneclinics.org. National Organization of Rare Disorders—a directory of support groups and information for patients and families with rare genetic disorders; http://www.rarediseases.org. OMIM: Online Mendelian Inheritance in Man—a complete listing of inherited genetic conditions; http://www.ncbi. nlm.nih.gov/omim/stats/html.
corneal arcus, abdominal pain of unexplained origin).
• Assess for muscular weakness.
The baseline information derived from the history assists in identifying pertinent issues related to the patient’s condition and educational and self-care needs. Once these problems are clearly identified, a plan of care is instituted. During subsequent contacts or visits with the patient, a more focused health history is performed to determine whether goals have been met, whether the plan needs to be modified, and whether new problems have developed. During the interview, the nurse asks questions to evaluate cardiac symptoms and health status.
• Dizziness and syncope or loss of consciousness (postural hypotension, dysrhythmias, vasovagal effect, cerebrovascular disorders)
Not all chest discomfort is related to myocardial ischemia. When a patient has chest discomfort, questions should focus on differentiating a serious, life-threatening condition such as MI from conditions that are less serious or that would be treated differently (see Table 26-2). The following points should be remembered when assessing patients with cardiac symptoms:
Cardiac Signs and Symptoms
• Women are more likely to present with atypical symptoms
Patients with cardiovascular disorders commonly have one or more of the following signs and symptoms:
• There is little correlation between the severity of the chest
of MI than are men.
• Chest pain or discomfort (angina pectoris, MI, valvular heart disease)
• Shortness of breath or dyspnea (MI, left ventricular failure, HF)
• Edema and weight gain (right ventricular failure, HF) • Palpitations (dysrhythmias resulting from myocardial is•
chemia, valvular heart disease, ventricular aneurysm, stress, electrolyte imbalance) Fatigue (earliest symptom associated with several cardiovascular disorders)
• • •
discomfort and the gravity of its cause. Elderly people and those with diabetes may not have pain with angina or MI because of neuropathies. Fatigue and shortness of breath may be the predominant symptoms in these patients. There is poor correlation between the location of chest discomfort and its source. The patient may have more than one clinical condition occurring simultaneously. In a patient with a history of CAD, the chest discomfort should be assumed to be secondary to ischemia until proven otherwise.
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NURSING ALERT People experiencing myocardial ischemia can have a variety of symptoms. The typical symptom is angina presenting as pressure, fullness, squeezing pain, or discomfort in the center of the chest. This pain may radiate to the shoulders, neck, jaw, or arms. Angina can also have an atypical or uncommon presentation, referred to as anginal equivalent. It is characterized by shortness of breath, fatigue, weakness, or pain in other parts of the upper body, including the neck, shoulder, jaw, arm, back, or stomach. Angina patterns are usually predictable (eg, with activity). Rest or sublingual nitroglycerin relieves symptoms within a few minutes. A patient in the midst of an MI, however, can present with angina or its equivalent symptoms, which last longer than 15 minutes. Signs and symptoms associated with an MI include lightheadedness, fainting, diaphoresis, unexplained anxiety, nausea, and shortness of breath. Symptoms are unrelieved by rest or nitroglycerin.
HEALTH PERCEPTION AND MANAGEMENT In an effort to determine how patients perceive their current health status. The nurse might ask some of the following questions: Do you have any health problems? If so, what do you think caused them? How has your health been recently? Have you noticed any changes from last year? from 5 years ago? Do you have a cardiologist or primary health care provider? How often do you go for checkups? Do you use tobacco or consume alcohol? What are your risk factors for heart disease? What do you do to stay healthy and take care of your heart? What prescription and over-the-counter medications are you taking? Do you take vitamins or herbal supplements? Some patients may not be aware of their own medical diagnosis. For example, patients may not realize that their heart attack was caused by CAD. Patients who do not understand that their behaviors or diagnoses pose a threat to their health may be less motivated to make lifestyle changes or to manage their illness effectively. On the other hand, patients who perceive that their modifiable cardiovascular risk factors have contributed to their health conditions may be more likely to change these behaviors (Chart 26-1). The patient’s ability to recognize cardiac symptoms and to know what to do when they occur is essential for effective self-care
management. All too often, patients’ new symptoms or symptoms of progressing cardiac dysfunction go unrecognized. This results in prolonged delays in seeking life-saving treatment. Major barriers to seeking prompt medical care include lack of knowledge about symptoms to expect with heart disease, attribution of symptoms to a benign source, psychological factors such as denial of symptom significance, and social factors, specifically feeling embarrassed about having symptoms (Zerwic, 1999). An additional issue to consider is the patient’s medication history, dosages, and schedules. Is the patient independent in taking medications? Are the medications taken as prescribed? Does the patient understand why the medication regimen is important? Are doses ever forgotten or skipped, or does the patient ever decide to stop taking a medication? An aspirin a day is a common nonprescription medication that improves patient outcomes after an MI. However, if patients are not aware of this benefit, they may be inclined to stop taking aspirin if they think it is a trivial medication. A careful medication history will often uncover common medication errors and causes for nonadherence to the medication regimen. Table 26-2 summarizes the characteristics and patterns of the more common cardiac and noncardiac causes of chest pain. Table 26-3 identifies typical questions nurses use to assess cardiac signs and symptoms, as well as those used to determine the patient’s ability to recognize and manage them. Some of the patient’s responses may require further clarification and follow-up. NUTRITION AND METABOLISM Dietary modifications, exercise, weight loss, and careful monitoring are important strategies for managing three major cardiovascular risk factors: hyperlipidemia, hypertension, and hyperglycemia (diabetes mellitus). Diets that are restricted in sodium, fat, cholesterol, and/or calories are commonly prescribed. The nurse should obtain the following information:
• The patient’s current height and weight (to determine body
• • •
Chart 26-1
Risk Factors for Heart Disease Nonmodifiable risk factors include the following: Positive family history for premature coronary artery disease Increasing age Gender (men and postmenopausal women) Race (higher incidence in African Americans than in Caucasians) Modifiable risk factors include the following: Hyperlipidemia Hypertension Cigarette smoking Elevated blood glucose level (ie, diabetes mellitus) Obesity Physical inactivity Type A personality characteristics, particularly hostility Use of oral contraceptives
• •
mass index), waist measurement (assessment for obesity), BP, and any laboratory test results such as blood glucose, glycosylated hemoglobin (diabetes), total blood cholesterol, high-density and low-density lipoprotein levels, and triglyceride levels (hyperlipidemia). How often the patient self-monitors BP, blood glucose, and weight as appropriate to the medical diagnoses. The patient’s level of awareness regarding his or her target goals for each of the risk factors and any problems achieving or maintaining these goals. What the patient normally eats and drinks in a typical day and any food preferences (including cultural or ethnic preferences). Eating habits (canned or commercially prepared foods versus fresh foods, restaurant cooking versus home cooking, assessing for high sodium foods, dietary intake of fats). Who shops for groceries and prepares meals.
ELIMINATION Typical bowel and bladder habits need to be identified. Nocturia (awakening at night to urinate) is common for patients with HF. Fluid collected in the dependent tissues (extremities) during the day redistributes into the circulatory system once the patient is recumbent at night. The increased circulatory volume is excreted by the kidneys (increased urine production). Patients need to be aware of their response to diuretic therapy and any changes in urination. This is vitally important for patients with HF. Patients may be taught to modify (titrate) their dose of diuretics based on urinary pattern, daily weight, and symptoms of dyspnea.
Chapter 26
Table 26-2
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• Assessing Chest Pain CHARACTER, LOCATION, AND RADIATION
DURATION
PRECIPITATING EVENTS
RELIEVING MEASURES
Angina Pectoris Substernal or retrosternal pain spreading across chest; may radiate to inside of arm, neck, or jaw
5–15 min
Usually related to exertion, emotion, eating, cold
Rest, nitroglycerin, oxygen
Substernal pain or pain over precordium; may spread widely throughout chest. Pain in shoulders and hands may be present.
>15 min
Occurs spontaneously but may be sequela to unstable angina
Morphine sulfate, successful reperfusion of blocked coronary artery
Sharp, severe substernal pain or pain to the left of sternum; may be felt in epigastrium and may be referred to neck, arms, and back
Intermittent
Sudden onset. Pain increases with inspiration, swallowing, coughing, and rotation of trunk.
Sitting upright, analgesia, antiinflammatory medications
Myocardial Infarction
Pericarditis
(continued)
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• Assessing Chest Pain (Continued) CHARACTER, LOCATION, AND RADIATION
DURATION
PRECIPITATING EVENTS
RELIEVING MEASURES
Pleuritic Pain Pain arises from inferior portion of pleura; may be referred to costal margins or upper abdomen. Patient may be able to localize the pain.
30+ min
Often occurs spontaneously. Pain occurs or increases with inspiration.
Rest, time. Treatment of underlying cause, bronchodilators.
Substernal pain; may be projected around chest to shoulders.
5–60 min
Recumbency, cold liquids, exercise. May occur spontaneously.
Food, antacid. Nitroglycerin relieves spasm.
Pain over chest; may be variable. Does not radiate. Patient may complain of numbness and tingling of hands and mouth.
2–3 min
Stress, emotional tachypnea
Removal of stimulus, relaxation
Esophageal Pain (Hiatal hernia, reflux esophagitis or spasm)
Anxiety
To avoid straining, patients who become easily constipated need to establish a regular bowel regimen. When straining, the patient tends to bear down (the Valsalva maneuver), which momentarily increases pressure on the baroreceptors. This triggers a vagal response, causing the heart rate to slow down and resulting in syncope in some patients. For the same reason, straining during urination should be avoided. Because many cardiac medications can cause gastrointestinal side effects or bleeding, the nurse asks about bloating, diarrhea, constipation, stomach upset, heartburn, loss of appetite, nausea, and vomiting. Patients taking platelet-inhibiting medications such as aspirin and clopidogrel (Plavix); intravenous GP IIb/IIIa platelet aggregation inhibitors such as abciximab (ReoPro), eptifibatide (Integrilin), and tirofiban (Aggrastat); and anticoagulants such as low-molecular-weight
heparin (ie, dalteparin [Fragmin]), enoxaparin (Lovenox), heparin, or warfarin (Coumadin) are screened for bloody urine or stools. ACTIVITY AND EXERCISE As the nurse assesses the patient’s activity and exercise history, it is important to note that decreases in activity tolerance are typically gradual and may go unnoticed by the patient. Therefore, the nurse needs to determine whether there has been a change in the activity pattern during the last 6 to 12 months. The patient’s subjective response to activity is an essential assessment parameter. New symptoms or a change in the usual angina or angina equivalent during activity is a significant finding. Fatigue, associated with low ejection fraction and certain medications (eg, beta-blockers), can result in activity intolerance. Patients with fatigue may benefit
Table 26-3
• Asking Questions to Evaluate Cardiac Problems
SYMPTOMS
ASSESSMENT QUESTIONS
ASSESSING PATIENT’S CAPACITY FOR SELF-MANAGEMENT
Chest pain, chest discomfort, angina pain
• Where is your pain (ask patient to point to location on chest) • What does the pain feel like? (pressure, heaviness, burning) • How severe is it on a scale of 0 to 10? • What causes the pain? (exertion, stress) • Does anything relieve it? (rest, nitroglycerin) • Does it spread to your arms, neck, jaw, shoulders, or back? • How long does the pain last? • Do you have any additional symptoms? (shortness of breath, palpitations, dizziness, sweating)
Shortness of breath, edema, weight gain
• When did you first notice feeling short of breath? • Do you have a cough? If yes, what do you cough up? • What makes you short of breath? Does anything make your breathing better or worse? • What activities are you no longer able to do because you are short of breath? • Do you ever wake up at night feeling short of breath? • What is your normal weight? • Have you had a recent weight gain? • Do you get up at night to urinate? Have you noticed an increase or decrease in the amount you usually urinate? • Have you noticed any weight gain or swelling in your feet, ankles, legs, or abdomen (sacrum if bedridden)? Do your shoes feel tight or clothes feel tight around your waist? • On how many pillows do you sleep, and has this changed recently? • Do you sleep in your bed, or do you breathe easier sleeping in a chair? • Do you ever feel your heart racing, skipping beats, or pounding? • Do you ever feel lightheaded or dizzy? • Are there any other symptoms that occur at the same time? • How much caffeine do you consume? • Do you use tobacco (cigarettes, cigars, chew)? • Do you use any other stimulants, recreational drugs? • Do you use any nutritional supplements or herbs? • Have there been any changes in the amount of stress you experience? • How would you describe your usual activity level? • What is your current activity level? • What were you able to do 1 month and 6 months ago? • What activities can you no longer do because of fatigue? • Do you feel rested when you wake up in the morning? • Can you rest during the day? • How often do you awaken at night, and for what reason?
Symptom Recognition • If you have angina, what does it usually feel like? • If you have angina, how do your angina symptoms differ from the discomfort caused by your other medical conditions? (indigestion, GI disorders) • How do you think you would tell the difference between the symptoms of angina and a heart attack? • What were you doing when the pain started? Symptom Management • What did you do when the pain started? • How long did you wait before seeking medical attention (calling the doctor, coming to the emergency department, or calling the ambulance) Use of Nitroglycerin • Do you have a prescription for nitroglycerin (NTG) tablets or spray? • At the time of your chest pain, did you use your NTG? • How many tablets or sprays did you use and how frequently? • If you have NTG and did not take it with this angina episode, why do you think you did not take it? • When did you first open your NTG container? Where is it stored? • Has anyone ever told you that you have heart failure? What does this mean to you? • Do you ever forget to take your diuretic medication (water pill) or other heart medicines or decide not to take them? If so, why do you think this happens? • What do you typically eat or drink? Who does the food shopping and meal preparation? • Are you on a sodium- or fluid-restricted diet? Have you been able to follow your special diet? • Do you have a scale to weigh yourself? How often do you weigh yourself? • What are important signs or symptoms to report to your doctor?
Palpitations
Fatigue
• What did you do when your symptoms first occurred? • Is your primary health care provider aware of these symptoms? • Are you taking medication for this condition, and have you been taking it as directed?
• Have you spoken with your primary health care provider about decreases in your activity level? • Has anyone ever taught you energy conservation techniques? If so, are you able to use them?
(continued)
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Table 26-3
CARDIOVASCULAR, CIRCULATORY, AND HEMATOLOGIC FUNCTION
• Asking Questions to Evaluate Cardiac Problems (Continued)
SYMPTOMS
ASSESSMENT QUESTIONS
ASSESSING PATIENT’S CAPACITY FOR SELF-MANAGEMENT
Dizziness, syncope (loss of consciousness)
• Do you ever feel dizzy or lightheaded? • Do you ever pass out or have fainting spells? • Does this happen when you move from a lying to a sitting or standing position? • Do you strain while having a bowel movement or when urinating? • Have you been urinating more than usual? • Have you decreased the amount of fluids you normally drink? • Do you have headaches?
• Have you ever been told you have high or low blood pressure? Has it been checked recently? • Are you taking any medications that can lower your blood pressure? • Before standing from a lying position, do you sit for a few minutes? Does that relieve the dizziness? • What are you using to prevent constipation?
from having their medications adjusted and learning energy conservation techniques. Additional areas to ask about include possible architectural barriers and challenges in the home, and what the patient does for exercise. If the patient exercises, the nurse asks additional questions: What is the intensity, and how long and how often is exercise performed? Has the patient ever participated in a cardiac rehabilitation program? Functional levels are known to improve for almost all patients who participate in a cardiac rehabilitation program, and attendance is highly recommended (Smith et al., 2001). Patients with disabilities may require an individually tailored exercise program. SLEEP AND REST Clues to worsening cardiac disease, especially HF, can be revealed by sleep-related events. Determining where the patient sleeps or rests is important. Recent changes, such as sleeping upright in a chair instead of in bed, increasing the number of pillows used, awakening short of breath at night (paroxysmal nocturnal dyspnea [PND]), or awakening with angina (nocturnal angina), are all indicative of worsening HF. COGNITION AND PERCEPTION Evaluating cognitive ability helps to determine whether the patient has the mental capacity to manage safe and effective selfcare. Is the patient’s short-term memory intact? Is there any history of dementia? Is there evidence of depression or anxiety? Can the patient read? Can the patient read English? What is the patient’s reading level? What is the patient’s preferred learning style? What information does the patient perceive as important? Providing the patient with written information can be a valuable part of patient education, but only if the patient can read and comprehend the information. Related assessments include possible hearing or visual impairments. If vision is impaired, patients with HF may not be able to weigh themselves independently nor keep records of weight, BP, pulse, or other data requested by the health care team. SELF-PERCEPTION AND SELF-CONCEPT Personality factors are associated with the development of and recovery from CAD. Most commonly cited is “type A behavior,” which is characterized by competitive, hard-driving behaviors and a sense of time urgency. Although this behavior is not an independent risk factor for CAD, anger and hostility (personality traits common in people with “type A behavior”) do affect the heart. People with these traits react to frustrating situations with an increase in BP, heart rate, and neuroendocrine responses. This
physiologic activation, called cardiac reactivity, is thought to trigger acute cardiovascular events (Woods et al., 1999). During the health history, the nurse discovers how patients feel about themselves by asking questions such as: How would you describe yourself? Have you changed the way you feel about yourself since your heart attack or surgery? Do you find that you are easily angered or hostile? How do you feel right now? What helps to manage these feelings? To fully evaluate this health pattern, assistance from a psychiatric clinical nurse specialist, psychologist, or psychiatrist may be necessary. ROLES AND RELATIONSHIPS Determining the patient’s social support systems is vitally important in today’s health care environment. Hospital stays for cardiac illnesses have shortened. Many invasive diagnostic cardiac procedures, such as cardiac catheterization and percutaneous transluminal coronary angioplasty (PTCA) are performed as outpatient procedures. Patients are discharged back into the community with activity limitations, such as driving restrictions, and with greater nursing care and educational needs. These needs have significant implications for people who are independent under normal circumstances, and for people who are at higher risk for problems, such as older adults. To assess support systems, the nurse needs to ask: Who is the primary caregiver? With whom does the patient live? Are there adequate services in place to provide a safe home environment? The nurse also assesses for any significant effects the cardiac illness has had on the patient’s role in the family. Are there adequate finances and health insurance? The answers to these questions will assist the nurse in developing a plan to meet the patient’s home care needs. SEXUALITY AND REPRODUCTION Although people recovering from cardiac illnesses or procedures are concerned about sexual activity, they are less likely to ask their nurse or other health care provider for information to help them resume their normal sex life. Lack of correct information and fear lead to reduced frequency and satisfaction with sexual activity. Therefore, nurses need to initiate this discussion with patients and not wait for them to bring it up in conversation. At first, inform the patient that it is common for people with similar heart problems to worry about resuming sexual activity. Then ask the patient to talk about his or her concerns. The most commonly cited reasons for changes in sexual activity are fear of another heart attack or sudden death; untoward symptoms such as angina, dyspnea, or palpitations; and problems
Chapter 26 with impotence or depression. In men, impotence may develop as a side effect of cardiac medications (beta-adrenergic blocking agents) and may prompt patients to stop taking them. Other medications can be substituted, so patients should be encouraged to discuss this problem with their health care provider. Often, patients and their partners do not have adequate information about the physical demands related to sexual activity and ways in which these demands can be modified. The physiologic demands are greatest during orgasm, reaching 5 or 6 metabolic equivalents (METs). This level of activity is equivalent to walking 3 to 4 miles per hour on a treadmill. The METs expended before and after orgasm are considerably less, at 3.7 METs (Steinke, 2000). Having this information may make patients and their partners more comfortable with resuming sexual activity. A reproductive history is necessary for women of childbearing age, particularly those with seriously compromised cardiac function. These women may be advised by their physicians not to become pregnant. The reproductive history includes information about previous pregnancies, plans for future pregnancies, oral contraceptive use (especially in women older than 35 years of age who are smokers), and use of hormone replacement therapy. COPING AND STRESS TOLERANCE It is important to determine the presence of psychosocial factors that adversely affect cardiac health. Anxiety, depression, and stress are known to influence both the development of and recovery from CAD. High levels of anxiety are associated with an increased incidence of CAD and increased in-hospital complication rates after MI. People with depression have an increased risk of MIand heart disease–related death, compared to people without depression. It is postulated that people who are depressed feel hopeless and are less motivated to make lifestyle changes and follow treatment plans, explaining the association between mortality and depression (Buselli & Stuart, 1999). Stress initiates a variety of physiologic responses, including increases in the circulation of catecholamines and cortisol, and has been strongly linked to cardiovascular events. Therefore, patients need to be assessed for presence of negative and positive emotions, as well as sources of stress. This is achieved by asking questions about recent or ongoing stressors, previous coping styles and effectiveness, and the patient’s perception of his or her current mood and coping ability. To adequately evaluate this health pattern, consultation with a psychiatric clinical nurse specialist, psychologist, or psychiatrist may be indicated. PREVENTION STRATEGIES Additional features of the health history include identification of risk factors and measures taken by the patient to prevent disease. The nurse’s questions need to focus on the patient’s health promotion practices. Epidemiologic studies show that certain conditions or behaviors (ie, risk factors) are associated with a greater incidence of coronary artery, peripheral vascular, and cerebrovascular disease. Risk factors are classified by the extent to which they can be modified by changing one’s lifestyle or modifying personal behaviors. Once a patient’s risk factors are determined, the nurse assesses whether the patient has a plan for making necessary behavioral changes and whether assistance is needed to support these lifestyle changes. For example, tobacco use is the most common avoidable cause of CAD. The first step in treating this health risk is to identify patients who use tobacco products and those who have recently quit. Because 70% of smokers visit a health care facility each
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year, nurses have ample opportunities to assess patients for tobacco use. For those who use tobacco, it is imperative to ask whether they are willing to quit. Provide cessation advice, motivation to quit, and relapse prevention strategies, as outlined in a U.S. Public Health Service report (The Tobacco Use and Dependence Clinical Practice Guideline Update Panel, Staff, and Consortium Representatives, 2000), can be delivered. For patients who have obesity, hyperlipidemia, hypertension, and diabetes, the nurse determines any problems the patient may be having following the prescribed management plan (ie, diet, exercise, and medications). It may be necessary to clarify the patient’s responsibilities, assist with finding additional resources, or make alternative plans for risk factor modification. Comprehensive secondary prevention strategies (early diagnosis and prompt intervention to halt or slow the disease process and its consequences) aimed at reducing cardiovascular risk factors improve overall survival, improve quality of life, reduce the need for revascularization procedures (coronary artery bypass surgery and PTCA), and reduce the incidence of subsequent MIs. The overall benefits of secondary prevention also apply to other patient groups with atherosclerotic vascular disease, including patients with transient ischemic attacks, stroke, and peripheral vascular disease (the leading cause of disability and death in these patients being CAD). Despite these findings, only one third of eligible patients, over the long term, adhere to risk factor interventions. Patient compliance increases significantly with a team approach that includes long-term follow-up with office or clinic visits and telephone contact (Smith et al., 2001).
PHYSICAL ASSESSMENT A physical examination is performed to confirm the data obtained in the health history. In addition to observing the patient’s general appearance, a cardiac physical examination should include an evaluation of the following:
• • • •
Effectiveness of the heart as a pump Filling volumes and pressures Cardiac output Compensatory mechanisms
Indications that the heart is not contracting sufficiently or functioning effectively as a pump include reduced pulse pressure, cardiac enlargement, and murmurs and gallop rhythms (abnormal heart sounds). The amount of blood filling the atria and ventricles and the resulting pressures (called filling volumes and pressures) are estimated by the degree of jugular vein distention and the presence or absence of congestion in the lungs, peripheral edema, and postural changes in BP that occur when the individual sits up or stands. Cardiac output is reflected by cognition, heart rate, pulse pressure, color and texture of the skin, and urine output. Examples of compensatory mechanisms that help maintain cardiac output are increased filling volumes and elevated heart rate. Note that the findings on the physical examination are correlated with data obtained from diagnostic procedures, such as hemodynamic monitoring (discussed later). The examination, which proceeds logically from head to toe, can be performed in about 10 minutes with practice and covers the following areas: (1) general appearance, (2) cognition, (3) skin, (4) BP, (5) arterial pulses, (6) jugular venous pulsations and pressures, (7) heart, (8) extremities, (9) lungs, and (10) abdomen.
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General Appearance and Cognition
Blood Pressure
The nurse observes the patient’s level of distress, level of consciousness, and thought processes as an indication of the heart’s ability to propel oxygen to the brain (cerebral perfusion). The nurse also observes for evidence of anxiety, along with any effects emotional factors may have on cardiovascular status. The nurse attempts to put the anxious patient at ease throughout the examination.
Systemic arterial BP is the pressure exerted on the walls of the arteries during ventricular systole and diastole. It is affected by factors such as cardiac output, distention of the arteries, and the volume, velocity, and viscosity of the blood. BP usually is expressed as the ratio of the systolic pressure over the diastolic pressure, with normal adult values ranging from 100/60 to 140/90 mm Hg. The average normal BP usually cited is 120/80 mm Hg. An increase in BP above the upper normal range is called hypertension (see Chap. 32 for further definitions and management), whereas a decrease below the lower range is called hypotension.
Inspection of the Skin Examination of the skin begins during the evaluation of the general appearance of the patient and continues throughout the assessment. It includes all body surfaces, starting with the head and finishing with the lower extremities. Skin color, temperature, and texture are assessed. The more common findings associated with cardiovascular disease are as follows.
• Pallor—a decrease in the color of the skin—is caused by
•
•
•
• •
•
•
lack of oxyhemoglobin. It is a result of anemia or decreased arterial perfusion. Pallor is best observed around the fingernails, lips, and oral mucosa. In patients with dark skin, the nurse observes the palms of the hands and soles of the feet. Peripheral cyanosis—a bluish tinge, most often of the nails and skin of the nose, lips, earlobes, and extremities—suggests decreased flow rate of blood to a particular area, which allows more time for the hemoglobin molecule to become desaturated. This may occur normally in peripheral vasoconstriction associated with a cold environment, in patients with anxiety, or in disease states such as HF. Central cyanosis—a bluish tinge observed in the tongue and buccal mucosa—denotes serious cardiac disorders (pulmonary edema and congenital heart disease) in which venous blood passes through the pulmonary circulation without being oxygenated. Xanthelasma—yellowish, slightly raised plaques in the skin—may be observed along the nasal portion of one or both eyelids and may indicate elevated cholesterol levels (hypercholesterolemia). Reduced skin turgor occurs with dehydration and aging. Temperature and moistness are controlled by the autonomic nervous system. Normally the skin is warm and dry. Under stress, the hands may become cool and moist. In cardiogenic shock, sympathetic nervous system stimulation causes vasoconstriction, and the skin becomes cold and clammy. During an acute MI, diaphoresis is common. Ecchymosis (bruise)—a purplish-blue color fading to green, yellow, or brown over time—is associated with blood outside of the blood vessels and is usually caused by trauma. Patients who are receiving anticoagulant therapy should be carefully observed for unexplained ecchymosis. In these patients, excessive bruising indicates prolonged clotting times (prothrombin or partial thromboplastin time) caused by an anticoagulant dosage that is too high. Wounds, scars, and tissue surrounding implanted devices should also be examined. Wounds are assessed for adequate healing, and any scars from previous surgeries are noted. The skin surrounding a pacemaker or implantable cardioverter defibrillator generator is examined for thinning, which could indicate erosion of the device through the skin.
BLOOD PRESSURE MEASUREMENT BP can be measured with the use of invasive arterial monitoring systems (discussed later) or noninvasively by a sphygmomanometer and stethoscope or by an automated BP monitoring device. A detailed description of the procedure for obtaining BP can be found in nursing skills textbooks, and specific manufacturer’s instructions review the proper use of the automated monitoring devices. Several important details must be observed to ensure that BP measurements are accurate; these are highlighted in Chart 26-2. PULSE PRESSURE The difference between the systolic and the diastolic pressures is called the pulse pressure. It is a reflection of stroke volume, ejection velocity, and systemic vascular resistance. Pulse pressure, which normally is 30 to 40 mm Hg, indicates how well the patient maintains cardiac output. The pulse pressure increases in conditions that elevate the stroke volume (anxiety, exercise, bradycardia), reduce systemic vascular resistance (fever), or reduce distensibility of the arteries (atherosclerosis, aging, hypertension). Decreased pulse pressure is an abnormal condition reflecting reduced stroke volume and ejection velocity (shock, HF, hypovolemia, mitral regurgitation) or obstruction to blood flow during systole (mitral or aortic
Chart 26-2
Ensuring Accurate Blood Pressure Measurement
• Cuff size must be appropriate for the patient. (The cuff size
• • • •
• • •
should have a bladder width at least 40% and length at least 80% of limb circumference.) The average adult cuff is 12 to 14 cm wide and 30 cm long. Using a cuff that is too small will give a high reading, whereas, too large a cuff results in a falsely low reading. Calibration of the sphygmomanometer should be performed routinely to ensure accuracy of blood pressure reading. Cuff is firmly wrapped around the arm, and cuff bladder is centered over the brachial artery. Patient’s arm should be at heart level. Initial recordings are made on both arms, and subsequent measurements are taken on the arm with the higher pressure. Normally, in the absence of disease of the vasculature, there is a difference of no more than 5 mm Hg between arm pressures. Position of the patient and site of blood pressure measurement (eg, RA for right arm) are recorded. Palpation of the systolic pressure before auscultation helps to detect an auscultatory gap more readily. The patient is asked not to talk during blood pressure measurements. A significant increase in blood pressure and heart rate occurs when subjects are talking.
Chapter 26 stenosis). A pulse pressure of less than 30 mm Hg signifies a serious reduction in cardiac output and requires further cardiovascular assessment. POSTURAL BLOOD PRESSURE CHANGES Postural (orthostatic) hypotension occurs when the BP drops significantly after the patient assumes an upright posture. It is usually accompanied by dizziness, lightheadedness, or syncope. Although there are many causes of postural hypotension, the three most common causes in patients with cardiac problems are a reduced volume of fluid or blood in the circulatory system (intravascular volume depletion, dehydration), inadequate vasoconstrictor mechanisms, and insufficient autonomic effect on vascular constriction. Postural changes in BP and an appropriate history help health care providers differentiate among these causes. The following recommendations are important when assessing postural BP changes:
• Position the patient supine and flat (as symptoms permit) • • • • • •
for 10 minutes before taking the initial BP and heart rate measurements. Check supine measurements before checking upright measurements. Do not remove the BP cuff between position changes, but check to see that it is still correctly placed. Assess postural BP changes with the patient sitting on the edge of the bed with feet dangling and, if appropriate, with the patient standing at the side of the bed. Wait 1 to 3 minutes after each postural change before measuring BP and heart rate. Be alert for any signs or symptoms of patient distress. If necessary, return the patient to a lying position before completing the test. Record both heart rate and BP and indicate the corresponding position (e.g., lying, sitting, standing) and any signs or symptoms that accompany the postural change.
Normal postural responses that occur when a person stands up or goes from a lying to a sitting position include (1) a heart rate increase of 5 to 20 bpm above the resting rate (to offset reduced stroke volume and maintain cardiac output); (2) an unchanged systolic pressure, or a slight decrease of up to 10 mm Hg; and (3) a slight increase of 5 mm Hg in diastolic pressure. A decrease in the amount of blood or fluid in the circulatory system should be suspected after diuretic therapy or bleeding, when a postural change results in an increased heart rate and either a decrease in systolic pressure by 15 mm Hg or a drop in the diastolic pressure by 10 mm Hg. Vital signs alone do not differentiate between a decrease in intravascular volume and inadequate constriction of the blood vessels as a cause of postural hypotension. With intravascular volume depletion, the reflexes that maintain cardiac output (increased heart rate and peripheral vasoconstriction) function correctly; the heart rate increases, and the peripheral vessels constrict. However, because of lost volume, the BP falls. With inadequate vasoconstrictor mechanisms, the heart rate again responds appropriately, but because of diminished peripheral vasoconstriction the BP drops. The following is an example of a postural BP recording showing either intravascular volume depletion or inadequate vasoconstrictor mechanisms: Lying down, BP 120/70, heart rate 70 Sitting, BP 100/55, heart rate 90 Standing, BP 98/52, heart rate 94
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In autonomic insufficiency, the heart rate is unable to increase to completely compensate for the gravitational effects of an upright posture. Peripheral vasoconstriction may be absent or diminished. Autonomic insufficiency does not rule out a concurrent decrease in intravascular volume. The following is an example of autonomic insufficiency as demonstrated by postural BP changes: Lying down, BP 150/90, heart rate 60 Sitting, BP 100/60, heart rate 60
Arterial Pulses Factors to be evaluated in examining the pulse are rate, rhythm, quality, configuration of the pulse wave, and quality of the arterial vessel. PULSE RATE The normal pulse rate varies from a low of 50 bpm in healthy, athletic young adults to rates well in excess of 100 bpm after exercise or during times of excitement. Anxiety frequently raises the pulse rate during the physical examination. If the rate is higher than expected, it is appropriate to reassess it near the end of the physical examination, when the patient may be more relaxed. PULSE RHYTHM The rhythm of the pulse is as important to assess as the rate. Minor variations in regularity of the pulse are normal. The pulse rate, particularly in young people, increases during inhalation and slows during exhalation. This is called sinus arrhythmia. For the initial cardiac examination, or if the pulse rhythm is irregular, the heart rate should be counted by auscultating the apical pulse for a full minute while simultaneously palpating the radial pulse. Any discrepancy between contractions heard and pulses felt is noted. Disturbances of rhythm (dysrhythmias) often result in a pulse deficit, a difference between the apical rate (the heart rate heard at the apex of the heart) and the peripheral rate. Pulse deficits commonly occur with atrial fibrillation, atrial flutter, premature ventricular contractions, and varying degrees of heart block. See Chapter 27 for a detailed discussion of these dysrhythmias. To understand the complexity of dysrhythmias that may be encountered during the examination, the nurse needs to have a sophisticated knowledge of cardiac electrophysiology, obtained through advanced education and training. PULSE QUALITY The quality, or amplitude, of the pulse can be described as absent, diminished, normal, or bounding. It should be assessed bilaterally. Scales can be used to rate the strength of the pulse. The following is an example of a 0-to-4 scale: 0 +1 +2 +3 +4
pulse not palpable or absent weak, thready pulse; difficult to palpate; obliterated with pressure diminished pulse; cannot be obliterated easy to palpate, full pulse; cannot be obliterated strong, bounding pulse; may be abnormal
The numerical classification is quite subjective; therefore, when documenting the pulse quality, it helps to specify a scale range (eg, “left radial +3/+4”). PULSE CONFIGURATION The configuration (contour) of the pulse conveys important information. In patients with stenosis of the aortic valve, the valve
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opening is narrowed, reducing the amount of blood ejected into the aorta. The pulse pressure is narrow, and the pulse feels feeble. In aortic insufficiency, the aortic valve does not close completely, allowing blood to flow back or leak from the aorta into the left ventricle. The rise of the pulse wave is abrupt and strong, and its fall is precipitous—a “collapsing” or “water hammer” pulse. The true configuration of the pulse is best appreciated by palpating over the carotid artery rather than the distal radial artery, because the dramatic characteristics of the pulse wave may be distorted when the pulse is transmitted to smaller vessels. EFFECT OF VESSEL QUALITY ON PULSE The condition of the vessel wall also influences the pulse and is of concern, especially in older patients. Once rate and rhythm have been determined, the nurse assesses the quality of the vessel by palpating along the radial artery and comparing it with normal vessels. Does the vessel wall appear to be thickened? Is it tortuous? To assess peripheral circulation, the nurse locates and evaluates all arterial pulses. Arterial pulses are palpated at points where the arteries are near the skin surface and are easily compressed against bones or firm musculature. Pulses are detected over the temporal, carotid, brachial, radial, femoral, popliteal, dorsalis pedis, and posterior tibial arteries. A reliable assessment of the pulses of the lower extremities depends on accurate identification of the location of the artery and careful palpation of the area. Light palpation is essential; firm finger pressure can easily obliterate the dorsalis pedis and posterior tibial pulses and confuse the examiner. In approximately 10% of patients, the dorsalis pedis pulses are not palpable. In such circumstances, both are usually absent together, and the posterior tibial arteries alone provide adequate blood supply to the feet. Arteries in the extremities are often palpated simultaneously to facilitate comparison of quality.
!
NURSING ALERT Do not palpate temporal or carotid arteries simultaneously, because it is possible to decrease the blood flow to the brain.
Heart Inspection and Palpation The heart is examined indirectly by inspection, palpation, percussion, and auscultation of the chest wall. A systematic approach is the cornerstone of a thorough assessment. Examination of the chest wall is performed in the following six areas (Fig. 26-6): 1. Aortic area—second intercostal space to the right of the sternum. To determine the correct intercostal space, start at the angle of Louis by locating the bony ridge near the top of the sternum, at the junction of the body and the manubrium. From this angle, locate the second intercostal space by sliding one finger to the left or right of the sternum. Subsequent intercostal spaces are located from this reference point by palpating down the rib cage. 2. Pulmonic area—second intercostal space to the left of the sternum 3. Erb’s point—third intercostal space to the left of the sternum 4. Right ventricular or tricuspid area—fourth and fifth intercostal spaces to the left of the sternum 5. Left ventricular or apical area—the PMI, location on the chest where heart contractions can be palpated 6. Epigastric area—below the xiphoid process For most of the examination, the patient lies supine, with the head slightly elevated. The right-handed examiner is positioned at the right side of the patient and the left-handed examiner at the left side. In a systematic fashion, each area of the precordium is inspected and then palpated. Oblique lighting is used to assist the examiner in identifying subtle pulsation. A normal impulse that is distinct and located over the apex of the heart is called the apical impulse (PMI). It may be observed in young people and in older people who are thin. The apical impulse is normally located and auscultated in the left fifth intercostal space in the midclavicular line (Fig. 26-7). In many cases, the apical impulse is palpable and is normally felt as a light pulsation, 1 to 2 cm in diameter. It is felt at the onset of the first heart sound and lasts for only half of systole. (See the next section for a discussion of heart sounds.) The nurse uses the palm of the hand to locate the apical impulse initially and the fingerpads to assess its size and quality. A broad and forceful apical impulse is
Jugular Venous Pulsations An estimate of right-sided heart function can be made by observing the pulsations of the jugular veins of the neck. This provides a means of estimating central venous pressure, which reflects right atrial or right ventricular end-diastolic pressure (the pressure immediately preceding the contraction of the right ventricle). Pulsations of the internal jugular veins are most commonly assessed. If they are difficult to see, pulsations of the external jugular veins may be noted. These veins are more superficial and are visible just above the clavicles, adjacent to the sternocleidomastoid muscles. The external jugular veins are frequently distended while the patient lies supine on the examining table or bed. As the patient’s head is elevated, the distention of the veins disappears. The veins normally are not apparent if the head of the bed or examining table is elevated more than 30 degrees. Obvious distention of the veins with the patient’s head elevated 45 degrees to 90 degrees indicates an abnormal increase in the volume of the venous system. This is associated with right-sided HF, less commonly with obstruction of blood flow in the superior vena cava, and rarely with acute massive pulmonary embolism.
Sternoclavicular area
Aortic area
Pulmonic area Erb’s point Right ventricular area Tricuspid area Left ventricular (apical) area Epigastric area Midsternum Midclavicular line
FIGURE 26-6
Areas of the precordium to be assessed when evaluating heart function. (Numerals identify ribs of adjacent intercostal spaces.)
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the right margin of the sternum and is not detectable. Enlargement of the heart to either the left or right usually can be noted. In people with thick chests, obesity, or emphysema, the heart may lie so deep under the thoracic surface that not even its left border can be noted unless the heart is enlarged. In such cases, unless the nurse detects a displaced apical impulse and suspects cardiac enlargement, percussion is omitted.
Cardiac Auscultation
A
B
FIGURE 26-7
Locating (A) and palpating (B) the apical impulse (also called the point of maximal impulse, PMI). The apical impulse normally is located at the fifth intercostal space to the left of the sternum at the midclavicular line. The nurse locates the impulse with the palm of the hand and palpates with the fingerpads. © B. Proud in Weber, J. W., & Kelley, J. (2003). Health assessment in nursing (2nd ed.). Philadelphia: Lippincott Williams & Wilkins.
known as a left ventricular heave or lift. It is so named because it appears to lift the hand from the chest wall during palpation. An apical impulse below the fifth intercostal space or lateral to the midclavicular line usually denotes left ventricular enlargement from left ventricular failure. Normally, the apical impulse is palpable in only one intercostal space; palpability in two or more adjacent intercostal spaces indicates left ventricular enlargement. If the apical impulse can be palpated in two distinctly separate areas and the pulsation movements are paradoxical (not simultaneous), a ventricular aneurysm should be suspected. Abnormal, turbulent blood flow within the heart may be palpated with the palm of the hand as a purring sensation. This phenomenon is called a thrill and is associated with a loud murmur. A thrill is always indicative of significant pathology within the heart. Thrills also may be palpated over vessels when blood flow is significantly and substantially obstructed and over the carotid arteries if aortic stenosis is present or if the aortic valve is narrowed.
Chest Percussion Normally, only the left border of the heart can be detected by percussion. It extends from the sternum to the midclavicular line in the third to fifth intercostal spaces. The right border lies under
All areas identified in Figure 26-6, except the epigastric area, are auscultated. These include the aortic area, the pulmonary area, Erb’s point, the tricuspid area, and the apical area. The actions of the four valves are uniquely reflected at specific locations on the chest wall. These locations do not correspond to the anatomic locations of the valves within the chest; rather, they reflect the patterns by which heart sounds radiate toward the chest wall. Sound in vessels through which blood is flowing is always reflected downstream. For example, the actions of the mitral valve are usually heard best in the fifth intercostal space at the midclavicular line. This is called the mitral valve area. HEART SOUNDS The normal heart sounds, S1 and S2, are produced primarily by the closing of the heart valves. The time between S1 and S2 corresponds to systole (Fig. 26-8). This is normally shorter than the time between S2 and S1 (diastole). As the heart rate increases, diastole shortens. In normal physiology, the periods of systole and diastole are silent. Ventricular disease, however, can give rise to transient sounds in systole and diastole that are called gallops, snaps, or clicks. Significant narrowing of the valve orifices at times when they should be open, or residual gapping of valves at times when they should be closed, gives rise to prolonged sounds called murmurs. S1—First Heart Sound. Closure of the mitral and tricuspid valves creates the first heart sound (S1), although vibration of the myocardial wall also may contribute to this sound. Although S1 is heard over the entire precordium, it is heard best at the apex of the heart (apical area). Its intensity increases when the valve leaflets are made rigid by calcium in rheumatic heart disease and in any circumstance in which ventricular contraction occurs at a time when the valve is caught wide open. The latter circumstance occurs, for example, when a premature ventricular contraction interrupts the normal cardiac cycle. S1 varies in intensity from beat to beat when atrial contraction is not synchronous with ventricular contraction. This is because the valve may be fully or partially closed on one beat and open on the subsequent one as a function of irregular atrial activity. S1 is easily identifiable and serves as the point of reference for the remainder of the cardiac cycle.
diastole
systole
S1
S2
diastole
systole
S1
S2
systole
S1
S2
FIGURE 26-8 Normal heart sounds. The first heart sound (S1) is produced by the closing of the mitral and tricuspid valves and is best heard at the apex of the heart (left ventricular or apical area). The second heart sound (S2) is produced by the closing of the aortic and pulmonic valves and is loudest at the base of the heart. The time between S1 and S2 corresponds to systole. The time between S2 and S1 is diastole.
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S2—Second Heart Sound. Closing of the aortic and pulmonic valves produces the second heart sound (S2). Although these two valves close almost simultaneously, the pulmonic valve usually lags slightly behind. Therefore, under certain circumstances, the two components of the second sound may be heard separately (split S2). The splitting is more likely to be accentuated on inspiration and to disappear on exhalation. (More blood is ejected from the right ventricle during inspiration than during exhalation.) S2 is heard loudest at the base of the heart. The aortic component of S2 is heard clearly in both the aortic and pulmonic areas, and less clearly at the apex. The pulmonic component of S2, if present, may be heard only over the pulmonic area. Therefore, one may hear a “single” S2 in the aortic area and a split S2 in the pulmonic area. Gallop Sounds. If the blood filling the ventricle is impeded during diastole, as occurs in certain disease states, then a temporary vibration may occur in diastole that is similar to, although usually softer than, S1 and S2. The heart sounds then come in triplets and have the acoustic effect of a galloping horse; they are called gallops. This may occur early in diastole, during the rapid-filling phase of the cardiac cycle, or later at the time of atrial contraction. A gallop sound occurring during rapid ventricular filling is called a third heart sound (S3); it represents a normal finding in children and young adults (Fig. 26-9A). Such a sound is heard in patients who have myocardial disease or in those who have HF and whose ventricles fail to eject all of their blood during systole. An S3 gallop is heard best with the patient lying on the left side. Gallop sounds heard during atrial contraction are called fourth heart sounds (S4) (see Fig. 26-9B). An S4 is often heard when the ventricle is enlarged or hypertrophied and therefore resistant to filling. Such a circumstance may be associated with CAD, hypertension, or stenosis of the aortic valve. On rare occasions, all four heart sounds are heard within a single cardiac cycle, giving rise to what is called a quadruple rhythm.
S3
S1
S2
S3
S1
S2
S3
S1
S2
A
S4
S1
S4 S2
S1
S4 S2
S1
S2
B
FIGURE 26-9
Gallops. (A) An S3 gallop is heard immediately following the S2 and occurs when the blood filling the ventricle is impeded during diastole, resulting in temporary vibrations. The heart sounds come in triplets and resemble the sound of a galloping horse. Myocardial disease and heart failure are associated with this sound. (B) An S4 gallop is heard immediately preceding the S1. The S4 sound occurs during atrial contraction and is often heard when the ventricle is enlarged or hypertrophied. Associated conditions include coronary artery disease, hypertension, and stenosis of the aortic valve.
Gallop sounds are very low-frequency sounds and may be heard only with the bell of the stethoscope placed very lightly against the chest. They are heard best at the apex, although occasionally, when emanating from the right ventricle, they may be heard to the left of the sternum. Snaps and Clicks. Stenosis of the mitral valve resulting from rheumatic heart disease gives rise to an unusual sound very early in diastole that is high-pitched and is best heard along the left sternal border. The sound is caused by high pressure in the left atrium with abrupt displacement of a rigid mitral valve. The sound is called an opening snap. It occurs too long after S2 to be mistaken for a split S2 and too early in diastole to be mistaken for a gallop. It almost always is associated with the murmur of mitral stenosis and is specific to this disorder. In a similar manner, stenosis of the aortic valve gives rise to a short, high-pitched sound immediately after S1 that is called an ejection click. This is caused by very high pressure within the ventricle, displacing a rigid and calcified aortic valve. Murmurs. Murmurs are created by the turbulent flow of blood. The causes of the turbulence may be a critically narrowed valve, a malfunctioning valve that allows regurgitant blood flow, a congenital defect of the ventricular wall, a defect between the aorta and the pulmonary artery, or an increased flow of blood through a normal structure (eg, with fever, pregnancy, hyperthyroidism). Murmurs are characterized and consequently described by several characteristics, including timing in the cardiac cycle, location on the chest wall, intensity, pitch, quality, and pattern of radiation (Chart 26-3). Friction Rub. In pericarditis, a harsh, grating sound that can be heard in both systole and diastole is called a friction rub. It is caused by abrasion of the pericardial surfaces during the cardiac cycle. Because a friction rub may be confused with a murmur, care should be taken to identify the sound and to distinguish it from murmurs that may be heard in both systole and diastole. A pericardial friction rub can be heard best using the diaphragm of the stethoscope, with the patient sitting up and leaning forward. AUSCULTATION PROCEDURE During auscultation, the patient remains supine and the examining room is as quiet as possible. A stethoscope with a diaphragm and a bell is necessary for accurate auscultation of the heart. Using the diaphragm of the stethoscope, the examiner starts at the apical area and progresses upward along the left sternal border to the pulmonic and aortic areas. If desired, the examiner may choose to begin the examination at the aortic and pulmonic areas and progress downward to the apex of the heart. Initially, S1 is identified and evaluated with respect to its intensity and splitting. Next, S2 is identified, and its intensity and any splitting are noted. After concentrating on S1 and S2, the examiner listens for extra sounds in systole and then in diastole. Sometimes it helps to ask the following questions: Do I hear snapping or clicking sounds? Do I hear any high-pitched blowing sounds? Is this sound in systole, or diastole, or both? The examiner again proceeds to move the stethoscope to all of the designated areas of the precordium, listening carefully for these sounds. Finally, the patient is turned on the left side and the stethoscope is placed on the apical area, where an S3, an S4, and a mitral murmur are more readily detected. Once an abnormality is heard, the entire chest surface is reexamined to determine the exact location of the sound and its
Chapter 26
Chart 26-3
Characteristics of Heart Murmurs
Heart murmurs are described in terms of location, timing, intensity, pitch, quality, and radiation. These characteristics provide data about the location and nature of the cardiac abnormality. Location The location of the murmur (where it is detected on the chest wall) is crucial. Depending on the type of valvular disorder, a murmur can be heard only at the apex or more widely over the chest wall, or along the left sternal border between the third and fourth interspaces. Timing Timing of the murmur in the cardiac cycle is vital. The examiner first determines whether the murmur is occurring in systole or in diastole. Then, does it begin simultaneously with a heart sound, or is there some delay between the sound and the beginning of the murmur? Does the murmur continue to (or through) the second heart sound, or is there a delay between the end of the murmur and the second heart sound? Are diastolic murmurs (between the second and first heart sounds) continuous, or do they subside in midor late diastole? Intensity The intensity of murmurs is conventionally graded from I through VI. Sometimes, grade I murmurs are difficult to hear. However, a grade II cardiac murmur can be easily perceived by the experienced examiner. Murmurs of grades IV or louder are usually associated with thrills that may be palpated on the surface of the chest wall. A grade VI murmur can be heard with the stethoscope off the chest. A murmur may vary in intensity from its beginning to its conclusion. This is very characteristic of certain valvular disorders. Pitch The next important characteristic of a murmur is its pitch, which may be low, often heard only with the bell of the stethoscope placed lightly on the chest wall, or a very high-pitched murmur, heard best with the stethoscope’s diaphragm. Other murmurs contain the full spectrum of sound frequency.
radiation. Also, the patient, who may be concerned about the prolonged examination, must be supported and reassured. The auscultatory findings, particularly murmurs, are documented by identifying the following characteristics:
heard the loudest.
INTERPRETATION OF CARDIAC SOUNDS Interpreting cardiac sounds requires detailed knowledge of cardiac physiology and the pathophysiology of cardiac diseases. There are different levels of performance at which the nurse may be expected to function. The first level is simply recognizing that what one is hearing is not normal—such as a third heart sound, a murmur in systole or diastole, a pericardial friction rub over the midsternum, or a second heart sound that is widely split. These findings are reported to the physician and acted on accordingly. This level of function is useful in screening. It is the kind of activity involved in performing physical examinations in schools on normal children or in performing routine physical examinations or screening examinations. The second level involves recognizing patterns. The nurse correctly observes the findings and can recognize the constellation of sounds and the diagnostic significance of common ones. At its most sophisticated level, cardiac diagnosis can be interpretive. Highly skilled nurses can differentiate among dysrhythmias and respond accordingly. They can determine the significance of the appearance and disappearance of gallops during the treatment of patients who have had MIs or who have HF. This is the role that the coronary care nurse and the cardiovascular advanced practice nurse assume. They function with a team of other health care professionals who have highly tuned skills of cardiovascular assessment and diagnosis.
Inspection of the Extremities The hands, arms, legs, and feet are observed for skin and vascular changes. The most noteworthy changes include the following:
• Decreased capillary refill time indicates a slower peripheral
•
•
• Location on chest wall. • Timing of sound as either during systole or during diastole;
• • •
described as early, middle, or late. (If heard throughout the systole, the sound is often referred to as pansystolic or holosystolic.) Intensity of the sound (I, very faint; II, quiet; III, moderately loud; IV, loud; V, very loud; or VI, heard with stethoscope removed from the chest). Pitch, desrcribed as high, medium, or low. Quality of the sound, commonly described as blowing, harsh, or musical.
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• Location of radiation of the sound away from where it is
Quality In addition to the intensity and pitch, the character of the sound. A murmur may be described as rumbling, blowing, whistling, harsh, or musical. Radiation The last feature of concern is radiation of the murmur. A murmur can radiate into the axilla, the carotid arteries in the neck, the left shoulder, or the back.
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flow rate from sluggish reperfusion and is often observed in patients with hypotension or HF. Capillary refill time provides the basis for estimating the rate of peripheral blood flow. To test capillary refill, briefly compress the nailbed so that it blanches, and then release the pressure. Normally, reperfusion occurs within 3 seconds, as evidenced by the return of color. Vascular changes from decreased arterial circulation include decrease in quality or loss of pulse, discomfort or pain, paresthesia, numbness, decrease in temperature, pallor, and loss of movement. During the first few hours after invasive cardiac procedures (eg, cardiac catheterization), affected extremities should be assessed for vascular changes frequently. Hematoma, or a localized collection of clotted blood in the tissue, may be observed in patients who have undergone invasive cardiac procedures such as cardiac catheterization, PTCA, or cardiac electrophysiology testing. Major blood vessels of the arms and legs are selected for catheter insertion. During these procedures, systemic anticoagulation with heparin is necessary, and minor or small hematomas may occur at the catheter puncture site. However, large hematomas are a serious complication that can compromise circulating blood volume and cardiac output, requiring blood transfusions. All patients who have undergone these procedures must have their puncture sites frequently observed until hemostasis is adequately achieved. Peripheral edema is fluid accumulation in dependent areas of the body (feet and legs, sacrum in the bedridden patient). Assess for pitting edema (a depression over an area of pres-
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sure) by pressing firmly for 5 seconds with the thumb over the dorsum of each foot, behind each medial malleolus, and over the shins. Pitting edema is graded as absent or as present on a scale from slight (1+ = 0 to 2 mm) to very marked (4+ = more than 8 mm). Peripheral edema is observed in patients with HF and in those with peripheral vascular diseases such as deep vein thrombosis or chronic venous insufficiency. Clubbing of the fingers and toes implies chronic hemoglobin desaturation, as in congenital heart disease. Lower extremity ulcers are observed in patients with arterial or venous insufficiency. Chapter 31 provides a complete description of differentiating characteristics.
Other Systems LUNGS The details of respiratory assessment are described in Chapter 21. Findings frequently exhibited by cardiac patients include the following: Tachypnea: Rapid, shallow breathing may be noted in patients who have HF or pain, and in those who are extremely anxious. Cheyne-Stokes respirations: Patients with severe left ventricular failure may exhibit Cheyne-Stokes breathing, a pattern of rapid respirations alternating with apnea. It is important to note the duration of the apnea. Hemoptysis: Pink, frothy sputum is indicative of acute pulmonary edema. Cough: A dry, hacking cough from irritation of small airways is common in patients with pulmonary congestion from HF. Crackles: HF or atelectasis associated with bed rest, splinting from ischemic pain, or the effects of pain medications and sedatives often results in the development of crackles. Typically, crackles are first noted at the bases (because of gravity’s effect on fluid accumulation and decreased ventilation of basilar tissue), but they may progress to all portions of the lung fields. Wheezes: Compression of the small airways by interstitial pulmonary edema may cause wheezing. Beta-adrenergic blocking agents (beta-blockers), such as propranolol (Inderal), may precipitate airway narrowing, especially in patients with underlying pulmonary disease. ABDOMEN For the cardiac patient, two components of the abdominal examination are frequently performed. Hepatojugular reflux: Liver engorgement occurs because of decreased venous return secondary to right ventricular failure. The liver is enlarged, firm, nontender, and smooth. The hepatojugular reflux may be demonstrated by pressing firmly over the right upper quadrant of the abdomen for 30 to 60 seconds and noting a rise of 1 cm or more in jugular venous pressure. This rise indicates an inability of the right side of the heart to accommodate increased volume. Bladder distention: Urine output is an important indicator of cardiac function, especially when urine output is reduced. This may indicate inadequate renal perfusion or a less serious problem such as one caused by urinary retention. When the urine output is decreased, the patient needs to be assessed for a distended bladder or difficulty voiding. The bladder may be assessed with an ultrasound scanner or
the suprapubic area palpated for an oval mass and percussed for dullness, indicative of a full bladder. Gerontologic Considerations When performing a cardiovascular examination on an elderly patient, the nurse may note such differences as more readily palpable peripheral pulses because of increased hardness of the arteries and a loss of adjacent connective tissue. Palpation of the precordium in the elderly is affected by the changes in the shape of the chest. For example, a cardiac impulse may not be palpable in patients with chronic obstructive pulmonary disease, because these patients usually have an increased anterior-posterior chest diameter. Kyphoscoliosis, a spinal deformity that occurs frequently in elderly patients, may dislocate the cardiac apex downward so that the diagnostic significance of palpating the apical impulse is obscured. Systolic BP increases with age, but diastolic BP usually plateaus after 50 years. Medication therapy is usually initiated for high BP when consistent systolic readings of 160 mm Hg or diastolic readings of 95 mm Hg are observed. For the elderly patient, however, many factors are considered before initiating treatment. Orthostatic hypotension may reflect a decreasing sensitivity of postural reflexes, which must be considered when medication therapy is prescribed. An S4 is heard in about 90% of elderly patients; this is thought to be caused by decreased compliance of the left ventricle. The S2 is usually split. At least 60% of elderly patients have murmurs, the most common being a soft systolic ejection murmur resulting from sclerotic changes of the aortic leaflets (see Table 26-1).
Diagnostic Evaluation Diagnostic tests and procedures are used to confirm the data obtained by history and physical assessment. Some tests are easy to interpret, but others must be interpreted by expert clinicians. All tests should be explained to the patient. Some necessitate special preparation before they are performed and special monitoring by the nurse after the procedure.
LABORATORY TESTS Laboratory tests may be performed for the following reasons:
• To assist in diagnosing an acute MI. (Angina pectoris, chest • • • • • • •
pain resulting from an insufficient supply of blood to the heart, cannot be confirmed by either blood or urine studies.) To identify abnormalities in the blood that affect the prognosis of a patient with a cardiac condition To assess the degree of inflammation To screen for risk factors associated with atherosclerotic coronary artery disease To determine baseline values before performing therapeutic interventions To monitor serum levels of medications To assess the effects of medications (e.g., the effects of diuretics on serum potassium levels) To screen generally for abnormalities
Because different laboratories use different equipment and different methods of measurements, normal test values may vary depending on the laboratory and the health care institution.
Chapter 26 Cardiac Enzyme Analysis Plasma cardiac enzyme analysis is part of a diagnostic profile that also includes the health history, symptoms, and electrocardiogram (ECG), associated with acute MI. Enzymes are released from injured cells when the cell membranes rupture. Most enzymes are nonspecific in relation to the particular organ that has been damaged. Certain isoenzymes, however, come only from myocardial cells and are released when the cells are damaged, such as by sustained hypoxia resulting in infarction or by trauma. The isoenzymes leak into the interstitial spaces of the myocardium and are carried into the general circulation by the lymphatic system and the coronary circulation, resulting in elevated serum enzyme concentrations. Because different enzymes move into the blood at varying periods after MI, enzyme levels should be tested in relation to the time of onset of chest discomfort or other symptoms. Creatine kinase (CK) and its isoenzyme CK-MB are the most specific enzymes analyzed in acute MI, and they are the first enzyme levels to rise. Lactic dehydrogenase and its isoenzymes also are analyzed in patients who have delayed seeking medical attention, because these blood levels rise and peak in 2 to 3 days, much later than CK levels (see Table 28-5 in Chap. 28 for the time course of cardiac enzymes). Myoglobin, an early marker of MI, is a heme protein with a small molecular weight. This allows it to be rapidly released from damaged myocardial tissue and accounts for its early rise, within 1 to 3 hours after the onset of an acute MI. Myoglobin peaks in 4 to 12 hours and returns to normal in 24 hours. Myoglobin is not used alone to diagnose MI, because elevations can also occur in patients with renal or musculoskeletal disease. However, negative results are helpful in ruling out an early diagnosis of MI. Troponin I is measured in a laboratory test that has several advantages over traditional enzyme studies. Troponin I is a contractile protein found only in cardiac muscle. After myocardial injury, elevated serum troponin I concentrations can be detected within 3 to 4 hours; they peak in 4 to 24 hours and remain elevated for 1 to 3 weeks. These early and prolonged elevations make very early diagnosis of MI possible or allow for late diagnosis if the patient has delayed seeking treatment.
Blood Chemistry LIPID PROFILE Cholesterol, triglycerides, and lipoproteins are measured to evaluate a person’s risk for developing atherosclerotic disease, especially if there is a family history of premature heart disease, or to diagnose a specific lipoprotein abnormality. Cholesterol and triglycerides are transported in the blood by combining with protein molecules to form lipoproteins. The lipoproteins are referred to as low-density lipoproteins (LDL) and high-density lipoproteins (HDL). The risk of CAD increases as the ratio of LDL to HDL or the ratio of total cholesterol (LDL + HDL) to HDL increases. Although cholesterol levels remain relatively constant over 24 hours, the blood specimen for the lipid profile should be obtained after a 12-hour fast. CHOLESTEROL LEVELS Cholesterol (normal level, less than 200 mg/dL) is a lipid required for hormone synthesis and cell membrane formation. It is found in large quantities in brain and nerve tissue. Two major sources of cholesterol are diet (animal products) and the liver, where cholesterol is synthesized. Elevated cholesterol levels are
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known to increase the risk for CAD. Factors that contribute to variations in cholesterol levels include age, gender, diet, exercise patterns, genetics, menopause, tobacco use, and stress levels. LDLs (normal level, less than 130 mg/dL) are the primary transporters of cholesterol and triglycerides into the cell. One harmful effect of LDL is the deposition of these substances in the walls of arterial vessels. Elevated LDL levels are associated with a greater incidence of CAD. In people with known CAD or diabetes, the primary goal for lipid management is reduction of LDL levels to less than 100 mg/dL. HDLs (normal range in men, 35 to 65 mg/dL; in women, 35 to 85 mg/dL) have a protective action. They transport cholesterol away from the tissue and cells of the arterial wall to the liver for excretion. Therefore, there is an inverse relationship between HDL levels and risk for CAD. Factors that lower HDL levels include smoking, diabetes, obesity, and physical inactivity. In patients with CAD, a secondary goal of lipid management is the increase of HDL levels to more than 40 mg/dL. Triglycerides (normal range, 40 to 150 mg/dL), composed of free fatty acids and glycerol, are stored in the adipose tissue and are a source of energy. Triglyceride levels increase after meals and are affected by stress. Diabetes, alcohol use, and obesity can elevate triglyceride levels. These levels have a direct correlation with LDL and an inverse one with HDL. SERUM ELECTROLYTE LEVELS Sodium, potassium, and calcium are ions that are vital to cellular depolarization and repolarization. In addition, the serum sodium concentration reflects relative fluid balance. Generally, hyponatremia (low sodium level) indicates fluid excess, and hypernatremia (high sodium level) indicates fluid deficit. Serum potassium is affected by renal function and may be decreased by diuretic agents that are used to treat HF. A decrease in potassium causes cardiac irritability and predisposes the patient receiving a digitalis preparation to digitalis toxicity and dysrhythmias. The effect of an elevated serum potassium concentration is myocardial depression and ventricular irritability. Both hypokalemia and hyperkalemia can lead to ventricular fibrillation or cardiac standstill. Calcium is necessary for blood coagulability and neuromuscular activity. Hypocalcemia and hypercalcemia can cause dysrhythmias. Magnesium is integral to the absorption of calcium and the maintenance of potassium stores. It is required in the metabolism of adenosine triphosphate, playing a major role in protein synthesis, carbohydrate metabolism, and muscular contraction. Initial symptoms of hypermagnesemia are lethargy and decreased neuromuscular activity. On the ECG, hypomagnesemia lengthens the QT interval, predisposing the patient to life-threatening dysrhythmias. BLOOD UREA NITROGEN LEVEL Blood urea nitrogen (BUN) is an end product of protein metabolism and is excreted by the kidneys. In the patient with cardiac disease, an elevated BUN level may reflect reduced renal perfusion (from decreased cardiac output) or intravascular fluid volume deficit (from diuretic therapy or dehydration). The cause of elevated BUN is determined from the serum creatinine: high BUN and high creatinine reflect renal impairment, high BUN and normal creatinine reflect intravascular fluid volume deficit. SERUM GLUCOSE LEVEL The serum glucose level is important to monitor, because many patients with cardiac disease also have diabetes mellitus. In addi-
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tion, the serum glucose level may be mildly elevated in stressful situations, when mobilization of endogenous epinephrine results in conversion of liver glycogen to glucose. Serum glucose levels are drawn in a fasting state. Glycosylated hemoglobin is an important measure to monitor in people with diabetes, because it reflects the blood glucose levels over 2 to 3 months. Hemoglobin A1C is the common name for this test. The goal of diabetes management is to maintain the hemoglobin A1C below 7% (normal range 4%–6%), reflecting consistent near-normal blood glucose levels. This is particularly important for primary and secondary prevention of CVD (Brundy et al., 2002; Smith et al., 2001).
Coagulation Studies The formation of a thrombus is initiated by injury to a vessel wall or to the tissue. These events activate the coagulation cascade, a complex series of interactions among phospholipids, calcium, and various clotting factors that converts prothrombin to thrombin. The coagulation cascade has two pathways, the intrinsic pathway and the extrinsic pathway. Coagulation studies are routinely performed before invasive procedures, such as cardiac catheterization, electrophysiology testing, and coronary or cardiac surgery. Partial thromboplastin time (PTT) and activated partial thromboplastin time (aPTT) measure the activity of the intrinsic pathway. The values of PTT and aPTT are used to assess the effects of heparin therapy. Patients receiving heparin have their PTT or aPTT levels maintained at 1.5 to 2.5 times their baseline values (reference range, 25 to 38 seconds). Prothrombin time (PT) measures the extrinsic pathway activity and is used to monitor the effects of therapeutic anticoagulation with warfarin (Coumadin). Laboratory results of PT also include the International Normalized Ratio (INR). The INR provides a standard method for reporting PT levels, eliminating the variation of PT results from laboratory to laboratory. The INR, rather than the PT alone, is used to monitor patients receiving warfarin therapy. The INR is maintained between 2.0 and 3.0 for patients with deep vein thrombosis, pulmonary embolism, valvular heart disease, or atrial fibrillation, and between 2.5 and 3.5 for patients with mechanical prosthetic heart valve replacements.
Hematologic Studies The complete blood cell count (CBC) identifies the total number of white and red blood cells, the platelet count, and the hemoglobin and hematocrit. The CBC is carefully monitored in patients with CVD. White blood cell counts are monitored in immunocompromised patients, including patients with transplanted hearts, and in situations where there is concern for infection (eg, after invasive procedures or surgery). The red blood cells carry hemoglobin, which transports oxygen to the cells. The hematocrit is a measure of the relative proportion of red blood cells and plasma. Low hemoglobin and hematocrit levels have serious consequences for patients with CAD, such as more frequent angina episodes. Platelets are the first line of protection against bleeding. Once activated by blood vessel wall injury or rupture of atherosclerotic plaque, platelets undergo chemical changes that form a thrombus. Patients are prescribed medications to inhibit platelet function, including aspirin, clopidogrel (Plavix), and intravenous GP IIb/IIIa inhibitors (abciximab [ReoPro], eptifibatide [Integrilin], tirofiban [Aggrastat]); therefore, it is essential to monitor for thrombocytopenia (low platelet counts). Chapter 33 provides an in-depth review of these laboratory tests and normal values.
CHEST X-RAY AND FLUOROSCOPY A chest x-ray usually is obtained to determine the size, contour, and position of the heart. It reveals cardiac and pericardial calcifications and demonstrates physiologic alterations in the pulmonary circulation. It does not help diagnose acute MI but can help diagnose some complications (eg, HF). Correct placement of cardiac catheters, such as pacemakers and pulmonary artery catheters, is also confirmed by chest x-ray. Fluoroscopy allows visualization of the heart on an x-ray screen. It shows cardiac and vascular pulsations and unusual cardiac contours. Fluoroscopy is useful for positioning intravenous pacing electrodes and for guiding catheter insertion during cardiac catheterization.
ELECTROCARDIOGRAPHY The ECG is a diagnostic tool used in assessing the cardiovascular system. It is a graphic recording of the electrical activity of the heart; an ECG can be recorded with 12, 15, or 18 leads, showing the activity from those different reference points. The ECG is obtained by placing disposable electrodes in standard positions on the skin of the chest wall and extremities. The heart’s electrical impulses are recorded as a tracing on special graph paper. The standard 12-lead ECG is the most commonly used tool to diagnose dysrhythmias, conduction abnormalities, enlarged heart chambers, myocardial ischemia or infarction, high or low calcium and potassium levels, and effects of some medications. A 15-lead ECG adds 3 additional chest leads across the right precordium and is a valuable tool for the early diagnosis of right ventricular and posterior left ventricular infarction. The 18-lead ECG adds 3 posterior leads to the 15-lead ECG and is very useful for early detection of myocardial ischemia and injury (Wung & Drew, 1999). To enhance interpretation of the ECG, the patient’s age, gender, BP, height, weight, symptoms, and medications (especially digitalis and antiarrhythmic agents) should be noted on the ECG requisition. The details of electrocardiography are covered in Chapter 27.
Continuous Electrocardiographic Monitoring Continuous ECG monitoring is standard for patients who are at high risk for dysrhythmias. Two continuous ECG monitoring techniques are hardwire monitoring, found in critical care units and specialty step-down units, and telemetry, found in specialty step-down units and general nursing care units. Patients who are receiving continuous ECG monitoring need to be informed of its purpose and cautioned that this monitoring method will not detect symptoms such as dyspnea or chest pain. Therefore, patients need to be advised to report symptoms to the nurse whenever they occur. HARDWIRE CARDIAC MONITORING The patient’s ECG can be continuously observed for dysrhythmias and conduction disorders on an oscilloscope at the bedside or at a central monitoring station by a hardwire monitoring system. This system is composed of three to five electrodes positioned on the patient’s chest, a lead cable, and a bedside monitor. Hardwire monitoring systems vary in sophistication but in general can do the following:
• Monitor more than one lead simultaneously • Monitor ST segments (ST-segment depression is a marker
of myocardial ischemia; ST-segment elevation provides evidence of an evolving MI)
Chapter 26 • Provide graded visual and audible alarms (based on prior• • •
ity, asystole would be highest) Computerize rhythm monitoring (dysrhythmias are interpreted and stored in memory) Print a rhythm strip Record a 12-lead ECG
Two leads commonly used for continuous monitoring are leads II and V1 or a modification of V1 (MCL1) (Fig. 26-10). Lead II provides the best visualization of atrial depolarization (represented by the P wave). Leads V1 and MCL1 best visualize the ventricle responsible for ectopic or abnormal ventricular beats. TELEMETRY In addition to hardwire monitoring systems, the ECG can be continuously observed by telemetry, the transmission of radiowaves from a battery-operated transmitter worn by the patient to a central bank of monitors. Although telemetry systems have the same capabilities as hardwire systems, they are wireless, allowing the patient to ambulate while being monitored. Following the guidelines for electrode placement will ensure good conduction and a clear picture of the patient’s rhythm on the monitor:
• Clean the skin surface with soap and water and dry well (or
• • •
as recommended by the manufacturer) before applying the electrodes. If the patient has much hair where the electrodes need to be placed, shave or clip the hair. Apply a small amount of benzoin to the skin if the patient is diaphoretic (sweaty) and the electrodes do not adhere well. Change the electrodes every 24 to 48 hours and examine the skin for irritation. Apply the electrodes to different locations each time they are changed. If the patient is sensitive to the electrodes, use hypoallergenic electrodes.
SIGNAL-AVERAGED ELECTROCARDIOGRAM For some patients who are considered to be at high risk for sudden cardiac death, a signal-averaged ECG is performed. This highresolution ECG assists in identifying the risk for life-threatening dysrhythmias and helps to determine the need for invasive diagnostic procedures. Signal averaging works by averaging about 150 to 300 QRS waveforms (QRS waveforms represent depolarization
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of the ventricle). The resulting averaged QRS complex is analyzed for certain characteristics that are likely to lead to lethal ventricular dysrhythmias. The recording is performed at the bedside and requires about 15 minutes. CONTINUOUS AMBULATORY MONITORING In ambulatory ECG monitoring, which may occur in the hospital but is more commonly prescribed for outpatients, one lead of the patient’s ECG can be monitored by a Holter monitor. This monitor is a small tape recorder that continuously (for 10 to 24 hours) documents the heart’s electrical activity on a magnetic tape. The tape recorder weighs approximately 2 pounds and can be carried over the shoulder or worn around the waist day and night to detect dysrhythmias or evidence of myocardial ischemia during activities of daily living. The patient keeps a diary of activity, noting the time of any symptoms, experiences, or unusual activities performed. The tape recording is then examined with a special scanner, analyzed, and interpreted. Evidence obtained in this way helps the physician diagnose dysrhythmias and myocardial ischemia and evaluate therapy, such as antiarrhythmic and antianginal medications or pacemaker function. TRANSTELEPHONIC MONITORING Another method of evaluating the ECG of a patient at home is by transtelephonic monitoring. The patient attaches a specific lead system for transmitting the signals and places a telephone mouthpiece over the transmitter box; the ECG is recorded and evaluated at another location. This method is often used for diagnosing dysrhythmias and in follow-up evaluation of permanent cardiac pacemakers.
CARDIAC STRESS TESTING Normally, the coronary arteries dilate to four times their usual diameter in response to increased metabolic demands for oxygen and nutrients. Coronary arteries with atherosclerosis, however, dilate much less, compromising blood flow to the myocardium and causing ischemia. Therefore, abnormalities in cardiovascular function are more likely to be detected during times of increased demand, or “stress.” The cardiac stress test procedures—the exercise stress test, the pharmacologic stress test, and, more recently, the mental or emotional stress test—are noninvasive ways to evaluate the response of the cardiovascular system to stress. The stress
FIGURE 26-10
Two leads (views of the heart) commonly used for continuous monitoring. To monitor lead II, the negative electrode is placed on the right upper chest; the positive electrode is placed on the left lower chest. To monitor MCL1, the negative electrode is placed on the left upper chest; the positive electrode is placed in the V1 position. If three electrodes are used, the third electrode, which is the ground electrode, can be placed anywhere on the chest.
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test helps determine the following: (1) CAD, (2) cause of chest pain, (3) functional capacity of the heart after an MI or heart surgery, (4) effectiveness of antianginal or antiarrhythmic medications, (5) dysrhythmias that occur during physical exercise, and (6) specific goals for a physical fitness program. Contraindications to stress testing include severe aortic stenosis, acute myocarditis or pericarditis, severe hypertension, suspected left main CAD, HF, and unstable angina. Because complications associated with stress testing can be life-threatening (MI, cardiac arrest, HF, and severe dysrhythmias), testing facilities must have staff and equipment ready to provide advanced cardiac life support. Mental stress testing uses a mental arithmetic test or simulated public speech to determine whether an ischemic myocardial response occurs, similar to the response evoked by a conventional treadmill exercise test. Although its use for diagnostic purposes in patients with CAD is currently investigational, preliminary results indicate that the ischemic and hemodynamic measures obtained from mental stress testing may be useful in assessing the prognosis of patients with CHD who have had a positive exercise test (Krantz et al., 1999). Stress testing is often combined with echocardiography or radionuclide imaging (discussed later). These techniques are performed during the resting state and immediately after stress.
Exercise Stress Testing In an exercise stress test, the patient walks on a treadmill (most common) or pedals a stationary bicycle or arm crank. Exercise intensity progresses according to established protocols. The Bruce protocol, for example, is a common treadmill protocol in which the speed and grade of the treadmill are increased every 3 minutes. The goal of the test is to increase the heart rate to the “target heart rate.” This is 80% to 90% of the maximum predicted heart rate and is based on the age and gender of the patient. During the test, the following are monitored: two or more ECG leads for heart rate, rhythm, and ischemic changes; BP; skin temperature; physical appearance; perceived exertion; and symptoms including chest pain, dyspnea, dizziness, leg cramping, and fatigue. The test is terminated when the target heart rate is achieved or when the patient experiences chest pain, extreme fatigue, a decrease in BP or pulse rate, serious dysrhythmias or ST segment changes on ECG, or other complications. When significant ECG abnormalities occur during the stress test (ST segment depressions), the test result is reported as positive and further diagnostic testing is required. NURSING INTERVENTIONS In preparation for the exercise stress test, the patient is instructed to fast for 4 hours before the test and to avoid stimulants such as tobacco and caffeine. Medications may be taken with sips of water. The physician may instruct patients not to take certain cardiac medications, such as beta-blockers, before the test. Clothes and sneakers or rubber-soled shoes suitable for exercising are to be worn. Women are advised to wear a bra that provides adequate support. The nurse describes the equipment used and the sensations and experiences that the patient may have during the test. The nurse explains the monitoring equipment used, the need to have an intravenous line placed, and the symptoms to report. The type of exercise is reviewed, and patients are asked to put forth their best exercise effort. If the test is to be performed with echocardiography or radionuclide imaging, this information is reviewed as well. After the test, patients are monitored for 10 to 15 minutes. Once stable, they may resume their usual activities.
Pharmacologic Stress Testing Physically disabled or deconditioned patients will not be able to achieve their target heart rate by exercising on a treadmill or bicycle. Two vasodilating agents, dipyridamole (Persantin) and adenosine (Adenocard), administered intravenously, are used to mimic the effects of exercise by maximally dilating the coronary arteries. The effects of dipyridamole last about 15 to 30 minutes. The side effects are related to its vasodilating action and include chest discomfort, dizziness, headache, flushing, and nausea. Adenosine has similar side effects, although patients report these symptoms as more severe. A unique property of adenosine is that it has an extremely short half-life (less than 10 seconds), so any severe effects rapidly subside. Dipyridamole and adenosine are the agents of choice used in conjunction with radionuclide imaging techniques. Theophylline and other xanthines, such as caffeine, block the effects of dipyridamole and adenosine and must be avoided before either of these pharmacologic stress tests. Dobutamine (Dobutrex) is another medication that may be used for patients who cannot exercise. Dobutamine, a synthetic sympathomimetic, increases heart rate, myocardial contractility, and BP, thereby increasing the metabolic demands of the heart. It is the agent of choice when echocardiography is used because of its effects on altering myocardial wall motion (due to enhanced contractility). In addition, dobutamine is used for patients who have bronchospasm or pulmonary disease and cannot tolerate having doses of theophylline withheld. NURSING INTERVENTIONS In preparation for the pharmacologic stress test, patients are instructed not to eat or drink anything for at least 4 hours before the test. This includes chocolate, caffeine, caffeine-free coffee, tea, carbonated beverages, or medications with caffeine (eg, Anacin, Darvon). If caffeine is ingested before a dipyridamole or adenosine stress test, the test will have to be rescheduled. Patients taking aminophylline or theophylline are instructed to stop taking these medications for 24 to 48 hours before the test (if tolerated). Oral doses of dipyridamole are to be withheld as well. Patients are informed about the transient sensations they may experience during infusion of the vasodilating agent, such as flushing or nausea, which will disappear quickly. The patient is instructed to report any other symptoms occurring during the test to the cardiologist or nurse. An explanation of echocardiography or radionuclide imaging is also provided as necessary. The stress test may take about 1 hour, or up to 3 hours if imaging is performed.
ECHOCARDIOGRAPHY Echocardiography is a noninvasive ultrasound test that is used to examine the size, shape, and motion of cardiac structures. It is a particularly useful tool for diagnosing pericardial effusions, determining the etiology of heart murmurs, evaluating the function of prosthetic heart valves, determining chamber size, and evaluating ventricular wall motion. It involves transmission of high-frequency sound waves into the heart through the chest wall and recording of the return signals. The ultrasound is generated by a hand-held transducer applied to the front of the chest. The transducer picks up the echoes, converts them to electrical impulses, and transmits them to the echocardiography machine for display on an oscilloscope and recording on a videotape. An ECG is recorded simultaneously to assist with interpreting the echocardiogram.
Chapter 26 M-mode (motion), the unidimensional mode that was first introduced, provides information about the cardiac structures and their motion. Two-dimensional or cross-sectional echocardiography (Fig. 26-11), an enhancement of the technique, creates a sophisticated, spatially correct image of the heart. Other techniques, such as Doppler and color flow imaging echocardiography, show the direction and velocity of the blood flow through the heart. As previously mentioned, echocardiography may be performed with an exercise or pharmacologic stress test; resting and stress images are obtained. Myocardial ischemia from decreased perfusion during stress causes abnormalities in ventricular wall motion and is easily detected by echocardiography. A stress test using echocardiography is considered positive if abnormalities in ventricular wall motion are detected during stress but not during rest. These findings are highly suggestive of CAD and require further evaluation, such as a cardiac catheterization.
Transesophageal Echocardiography A significant limitation of traditional echocardiography has been the poor quality of the images produced. Ultrasound loses its clarity as it passes through tissue, lung, and bone. Another echocardiographic technique involves threading a small transducer through the mouth and into the esophagus. This technique, called transesophageal echocardiography (TEE), provides clearer images because ultrasound waves are passing through less tissue. Pharmacologic stress testing using dobutamine and TEE can also be performed. The high-quality imaging obtained during TEE makes this technique an important adjunct to the technology available for detecting and evaluating the severity of CAD. Complications are uncommon during TEE, but if they do occur they are serious. These complications are caused by sedation and impaired swallowing from topical anesthesia (respiratory depression and aspiration) and by insertion and manipulation of the transducer into the esophagus and stomach (vasovagal response or esophageal perforation). The patient must be assessed before TEE for a history of dysphagia or radiation therapy to the chest that would increase the risk for complications.
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NURSING INTERVENTIONS Before traditional echocardiography, the nurse informs the patient about the test, explaining that it is painless. Echocardiographic monitoring is performed while a transducer that emits the sound waves is moved about the chest. Gel applied to the skin helps transmit the sound waves. Periodically, the patient will have to turn onto the left side or hold a breath. The test takes about 30 to 45 minutes. If the patient is to undergo an exercise or pharmacologic stress test with echocardiography, information on stress testing is also reviewed. In preparation for a TEE study, the following information is reviewed:
• The patient must fast for 6 hours before the study. • An intravenous line is started for administering a sedative and any pharmacologic stress testing medications.
• The patient’s throat is anesthetized before the probe is inserted.
• BP and the ECG are monitored throughout the study. • The patient will be kept comfortable but not heavily sedated. The patient must be alert enough to follow instructions and to report symptoms such as chest pain.
After the study, monitoring continues for 30 to 60 minutes. The patient is to continue fasting for 4 hours. The patient may have a sore throat for the next 24 hours.
RADIONUCLIDE IMAGING Radionuclide imaging studies involve the use of radioisotopes to evaluate coronary artery perfusion noninvasively, to detect myocardial ischemia and infarction, and to assess left ventricular function. Radioisotopes are atoms in an unstable form. Thallium 201 (Tl201) and technetium 99m (Tc99m) are two of the most common radioisotopes used in cardiac nuclear medicine studies. As they decay, they give off small amounts of energy in the form of gamma rays. When they are injected intravenously into the bloodstream, the energy emitted by the radioisotope can be detected by a gamma scintillation camera positioned over the body. Planar imaging, used with thallium, is a technique that provides a one-dimensional view of the heart from three locations. A relatively new technique called single photon emission computed tomography (SPECT) provides three-dimensional images. With SPECT, the patient is positioned supine with arms raised above the head, while the camera moves around the patient’s chest in a 180- to 360-degree arc to identify the areas of decreased myocardial perfusion more precisely.
Myocardial Perfusion Imaging
FIGURE 26-11 Two-dimensional echocardiogram, four-chamber view in a normal patient. The ventricles and atria are the dark areas outlined by the white. LA = left atrium, LV = left ventricle, RA = right atrium, RV = right ventricle. Courtesy of V. Bowles, RCS, CCT, Inova Alexandria Hospital, Alexandria, Virginia.
The radioisotope Tl201 is used to assess myocardial perfusion. It resembles potassium and readily crosses into the cells of healthy myocardium. It is taken up more slowly and in smaller amounts by myocardial cells that are ischemic from decreased blood flow. However, thallium will not cross into the necrotic tissue that results from an MI. Often, thallium is used with stress testing to assess changes in myocardial perfusion immediately after exercise (or after injection of one of the agents used in stress testing) and at rest. One or two minutes before the end of the stress test, a dose of Tl201 is injected into the intravenous line, allowing the radioisotope to be distributed into the myocardium. Images are taken immediately. Areas that do not show thallium uptake are noted as defects and indicate areas of either infarction or stress-induced myocardial
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ischemia. The resting images, taken 3 hours later, help to differentiate infarction from ischemia. Infarcted tissue is unable to take up thallium regardless of when the scan is taken; the defect remains the same size. This is called a fixed defect, indicating that there is no perfusion in that area of the myocardium. Ischemic myocardium, on the other hand, recovers in a few hours. Once perfusion is restored, thallium crosses into the myocardial cells, and the area of defect on the resting images is either smaller or completely reversed. These reversible defects constitute positive stress test findings. Usually, cardiac catheterization is recommended after a positive test result to determine whether angioplasty or coronary artery bypass graft surgery is needed. Another radioisotope used for cardiac imaging is Tc99m. Technetium can be combined with various chemical compounds, giving it an affinity for different types of cells. For example, Tc99m sestamibi (Cardiolite) is distributed to myocardial cells in proportion to their amount of perfusion, making this tracer excellent for assessing perfusion to the myocardium. The procedure for cardiac imaging using Tc99m sestamibi with stress testing is similar to the one using thallium, with two differences. Patients receiving Tc99m sestamibi can have their resting images recorded before or after the exercise images. Timing of the images is not important because the half-life of Tc99m is short, and Tc99m needs to be injected before each scan. Also, SPECT imaging with Tc99m sestamibi provides high-quality images. NURSING INTERVENTIONS The patient undergoing nuclear imaging techniques with stress testing should be prepared for the type of stressor to be used (exercise or drug) and the type of imaging technique (planar or SPECT). The patient may be concerned about receiving a radioactive substance and needs to be reassured that these tracers are safe, the radiation exposure being similar to that of other diagnostic x-ray studies. No postprocedure radiation precautions are necessary. When providing teaching for patients undergoing SPECT, the nurse should instruct them that their arms will need to be positioned over their head for about 20 to 30 minutes. If they are physically unable to do this, thallium with planar imaging can be used.
Test of Ventricular Function and Wall Motion Equilibrium radionuclide angiocardiography (ERNA), also known as multiple-gated acquisition (MUGA) scanning, is a common noninvasive technique that uses a conventional scintillation camera interfaced with a computer to record images of the heart during several hundred heartbeats. The computer processes the data and allows for sequential viewing of the functioning heart. The sequential images are analyzed to evaluate left ventricular function, wall motion, and ejection fraction. MUGA scanning can also be used to assess the differences in left ventricular function during rest and exercise. The patient is reassured that there is no known radiation danger and is instructed to remain motionless during the scan.
Computed Tomography Computed tomography (CT), also called computerized axial tomographic (CAT) scanning or electron-beam computed tomography (EBCT), uses x-rays to provide cross-sectional images of the chest, including the heart and great vessels. These techniques are used to evaluate cardiac masses and diseases of the aorta and pericardium.
EBCT, also known as the Ultrafast CT, is an especially fast x-ray scanning technique that results in much faster image acquisition with a higher degree of resolution than traditional x-ray or CT scanning provides (Woods et al., 1999). It is used to evaluate bypass graft patency, congenital heart lesions, left and right ventricular muscle mass, chamber volumes, cardiac output, and ejection fraction. For people without previous MI, PTCA, or coronary artery bypass surgery, the EBCT is used to determine the amount of calcium deposits in the coronary arteries and underlying atherosclerosis. From this scan, a calcium score is derived that predicts the incidence of cardiac events, such as MI or the need for a revascularization procedure within the next 1 to 2 years. The EBCT is not widely used, but it does show great promise for early detection of CAD that is not yet clinically significant and that would not be identified by traditional testing methods, such as the exercise stress test. NURSING INTERVENTIONS Patient preparation is the primary role of the nurse for these tests. The nurse should instruct the patient that he will be positioned on a table during the scan while the scanner rotates around him. The procedure is noninvasive and painless. However, to obtain adequate images, the patient must lie perfectly still during the scanning process. An intravenous access line is necessary if contrast enhancement is to be used.
Positron Emission Tomography Positron emission tomography (PET) is a noninvasive scanning method that was used in the past primarily to study neurologic dysfunction. More recently, and with increasing frequency, PET has been used to diagnose cardiac dysfunction. PET provides more specific information about myocardial perfusion and viability than does TEE or thallium scanning. For cardiac patients, including those without symptoms, PET helps in planning treatment (eg, coronary artery bypass surgery, angioplasty). PET also helps evaluate the patency of native and previously grafted vessels and the collateral circulation. During a PET scan, radioisotopes are administered by injection; one compound is used to determine blood flow in the myocardium, and another shows the metabolic function. The PET camera provides detailed three-dimensional images of the distributed compounds. The viability of the myocardium is determined by comparing the extent of glucose metabolism in the myocardium to the degree of blood flow. For example, ischemic but viable tissue would show decreased blood flow and elevated metabolism. For a patient with this finding, revascularization through surgery or angioplasty would be likely to improve heart function. Restrictions of food intake before the test vary among institutions, but, because PET evaluates glucose metabolism, the patient’s blood glucose level should be in the normal range. Although PET equipment is costly, it is increasingly valued and available. NURSING INTERVENTIONS Nurses involved in PET and other scanning procedures may instruct the patient to refrain from using tobacco and ingesting caffeine for 4 hours before the procedure. They should also reassure the patient that radiation exposure is at safe and acceptable levels, similar to those of other diagnostic x-ray studies.
Chapter 26 Magnetic Resonance Imaging Magnetic resonance imaging (MRI) is a noninvasive, painless technique that is used to examine both the physiologic and anatomic properties of the heart. MRI uses a powerful magnetic field and computer-generated pictures to image the heart and great vessels. It is valuable in diagnosing diseases of the aorta, heart muscle, and pericardium, as well as congenital heart lesions. The application of this technique to the evaluation of coronary artery anatomy, cardiac blood flow, and myocardial viability in conjunction with pharmacologic stress testing is being investigated. NURSING INTERVENTIONS Because of the strong magnetic field used during MRI, diagnostic centers where these procedures are performed carefully screen patients for contraindications. Standardized questionnaires are commonly used to determine whether the patient has a pacemaker, metal plates, prosthetic joints, or other metallic implants that can become dislodged if exposed to MRI. During an MRI, the patient is positioned supine on a table that is placed into an enclosed imager or tube that contains the magnetic field. People who are claustrophobic may need to receive a mild sedative before undergoing an MRI. As the MRI is performed, there is an intermittent clanking or thumping sound from the magnetic coils that can be annoying to the patient, so patients are offered headsets to listen to music. The scanner is equipped with a microphone so that the patient can communicate with the staff. During the scanning, the patient is instructed to remain still and not move.
!
NURSING ALERT No metal can be in the MRI room because metal objects can become dangerous projectiles; this includes such items as clipboards, paperclips, oxygen tanks, and monitors.
CARDIAC CATHETERIZATION Cardiac catheterization is an invasive diagnostic procedure in which radiopaque arterial and venous catheters are introduced into selected blood vessels of the right and left sides of the heart. Catheter advancement is guided by fluoroscopy. Most commonly, the catheters are inserted percutaneously through the blood vessels, or via a cutdown procedure if the patient has poor vascular access. Pressures and oxygen saturations in the four heart chambers are measured. Cardiac catheterization is used to diagnose CAD, assess coronary artery patency, and determine the extent of atherosclerosis based on the percentage of coronary artery obstruction. These results determine whether revascularization procedures including PTCA or coronary artery bypass surgery may be of benefit to the patient (see Chap. 28). During cardiac catheterization, the patient has an intravenous line in place for the administration of sedatives, fluids, heparin, and other medications. Noninvasive hemodynamic monitoring that includes BP and multiple ECG tracings is necessary to continuously observe for dysrhythmias or hemodynamic instability. The myocardium can become ischemic and trigger dysrhythmias as catheters are positioned in the coronary arteries or during injection of contrast agents. Resuscitation equipment must be readily available during the procedure. Staff must be prepared to provide advanced cardiac life support measures as necessary. Radiopaque contrast agents are used to visualize the coronary arteries; some contrast agents contain iodine. The patient is as-
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sessed before the procedure for previous reactions to contrast agents or allergies to iodine-containing substances (eg, seafood). If the patient has a suspected or known allergy to the substance, antihistamines or methylprednisolone (Solu-Medrol) may be administered before the procedure. In addition, the following blood tests are performed to identify abnormalities that may complicate recovery: BUN and creatinine levels, INR or PT, aPTT, hematocrit and hemoglobin values, platelet count, and electrolyte levels. Diagnostic cardiac catheterizations are commonly performed on an outpatient basis and require 2 to 6 hours of bed rest before ambulation. For most patients, bed rest for 6 hours compared to 2 hours has no advantage with regard to groin bleeding complications (Logemann et al., 1999). However, variations in time to ambulation are most often related to the size of the catheter used during the procedure, the anticoagulation status of the patient, other patient variables (eg, advanced age, obesity, bleeding disorder), the method used for hemostasis of the arterial puncture site after the procedure, and institutional policies. The use of smaller (4 or 6 Fr) catheters, which are more amenable to shorter recovery times, is common in diagnostic cardiac catheterizations. There are several methods available to achieve arterial hemostasis after catheter removal, including manual pressure, mechanical compression devices such as the FemoStop (placed over puncture site for 30 minutes), and percutaneously deployed devices. The latter devices are positioned at the femoral arterial puncture site after completion of the procedure. They deploy collagen (VasoSeal), sutures (Perclose, Techstar), or a combination of both (AngioSeal). Major benefits of these devices include reliable, immediate hemostasis and shorter time on bed rest without a significant increase in bleeding or other complications (Baim et al., 2000). A number of factors determine which hemostatic methods are used and are based on the physician’s preference, the patient’s condition, cost, and institutional availability of the equipment. Patients hospitalized for angina or acute MI may also require cardiac catheterization. After the procedure, these patients usually return to their hospital rooms for recovery. In some cardiac catheterization laboratories, an angioplasty may be performed immediately after the catheterization if indicated.
ANGIOGRAPHY Cardiac catheterization is usually performed with angiography, a technique of injecting a contrast agent into the vascular system to outline the heart and blood vessels. When a particular heart chamber or blood vessel is singled out for study, the procedure is known as selective angiography. Angiography makes use of cineangiograms, a series of rapidly changing films on an intensified fluoroscopic screen that record the passage of the contrast agent through the vascular site or sites. The recorded information allows for comparison of data over time. Common sites for selective angiography are the aorta, the coronary arteries, and the right and left sides of the heart.
Aortography An aortogram is a form of angiography that outlines the lumen of the aorta and the major arteries arising from it. In thoracic aortography, a contrast agent is used to study the aortic arch and its major branches. The catheter may be introduced into the aorta using the translumbar or retrograde brachial or femoral artery approach.
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Coronary Arteriography In coronary arteriography, the catheter is introduced into the right or left brachial or femoral artery, then passed into the ascending aorta and manipulated into the appropriate coronary artery. Coronary arteriography is used to evaluate the degree of atherosclerosis and to guide the selection of treatment. It is also used to study suspected congenital anomalies of the coronary arteries.
Right Heart Catheterization Right heart catheterization usually precedes left heart catheterization. It involves the passage of a catheter from an antecubital or femoral vein into the right atrium, right ventricle, pulmonary artery, and pulmonary arterioles. Pressures and oxygen saturations from each of these areas are obtained and recorded. Although right heart catheterization is considered a relatively safe procedure, potential complications include cardiac dysrhythmias, venous spasm, infection of the insertion site, cardiac perforation, and, rarely, cardiac arrest.
Left Heart Catheterization Left heart catheterization is performed to evaluate the patency of the coronary arteries and the function of the left ventricle and the mitral and aortic valves. Potential complications include dysrhythmias, MI, perforation of the heart or great vessels, and systemic embolization. Left heart catheterization is performed by retrograde catheterization of the left ventricle. In this approach, the physician usually inserts the catheter into the right brachial artery or a femoral artery and advances it into the aorta and left ventricle. After the procedure, the catheter is carefully withdrawn and arterial hemostasis is achieved using manual pressure or other techniques previously described. If the physician performed an arterial or venous cutdown, the site is sutured and a sterile dressing is applied. NURSING INTERVENTIONS Nursing responsibilities before cardiac catheterization include the following:
• Instruct the patient to fast, usually for 8 to 12 hours, before
• • •
the procedure. If catheterization is to be performed as an outpatient procedure, explain that a friend, family member, or other responsible person must transport the patient home. Prepare the patient for the expected duration of the procedure; indicate that it will involve lying on a hard table for less than 2 hours. Reassure the patient that mild sedatives or moderate sedation will be given intravenously. Prepare the patient to experience certain sensations during the catheterization. Knowing what to expect can help the patient cope with the experience. Explain that an occasional pounding sensation (palpitation) may be felt in the chest because of extrasystoles that almost always occur, particularly when the catheter tip touches the myocardium. The patient may be asked to cough and to breathe deeply, especially after the injection of contrast agent. Coughing may help to disrupt a dysrhythmia and to clear the contrast agent from the arteries. Breathing deeply and holding the breath helps to lower the diaphragm for better visualization of heart structures. The injection of a contrast agent into either side
•
of the heart may produce a flushed feeling throughout the body and a sensation similar to the need to void, which subsides in 1 minute or less. Encourage the patient to express fears and anxieties. Provide teaching and reassurance to reduce apprehension.
Nursing responsibilities after cardiac catheterization may include the following: 1. Observe the catheter access site for bleeding or hematoma formation, and assess the peripheral pulses in the affected extremity (dorsalis pedis and posterior tibial pulses in the lower extremity, radial pulse in the upper extremity) every 15 minutes for 1 hour, and then every 1 to 2 hours until the pulses are stable. 2. Evaluate temperature and color of the affected extremity and any patient complaints of pain, numbness, or tingling sensations to determine signs of arterial insufficiency. Report changes promptly. 3. Monitor for dysrhythmias by observing the cardiac monitor or by assessing the apical and peripheral pulses for changes in rate and rhythm. A vasovagal reaction, consisting of bradycardia, hypotension, and nausea, can be precipitated by a distended bladder or by discomfort during removal of the arterial catheter, especially if a femoral site has been used. Prompt intervention is critical; this includes raising the feet and legs above the head, administering intravenous fluids, and administering intravenous atropine. 4. Inform the patient that if the procedure is performed percutaneously through the femoral artery (and without the use of devices such as VasoSeal, Perclose, or Angio-Seal), the patient will remain on bed rest for 2 to 6 hours with the affected leg straight and the head elevated to 30 degrees (Logemann et al., 1999). For comfort, the patient may be turned from side to side with the affected extremity straight. If the cardiologist uses deployed devices, check local nursing care standards, but anticipate that the patient will have less restrictions on elevation of the head of the bed and will be allowed to ambulate in 2 hours or less (Baim et al., 2000). Analgesic medication is administered as prescribed for discomfort. 5. Instruct the patient to report chest pain and bleeding or sudden discomfort from the catheter insertion sites immediately. 6. Encourage fluids to increase urinary output and flush out the dye. 7. Ensure safety by instructing the patient to ask for help when getting out of bed the first time after the procedure, because orthostatic hypotension may occur and the patient may feel dizzy and lightheaded. For patients being discharged from the hospital on the same day as the procedure, additional instructions are provided. They appear in Chart 26-4.
ELECTROPHYSIOLOGIC TESTING The electrophysiology study (EPS) is an invasive procedure that plays a major role in the diagnosis and management of serious dysrhythmias and is used (1) to distinguish atrial from ventricular tachycardias when the determination cannot be made from the 12-lead ECG, (2) to evaluate how readily a life-threatening dysrhythmia (eg, ventricular tachycardia, ventricular fibrillation)
Chapter 26
Chart 26-4
• PATIENT EDUCATION
Self-Management After Cardiac Catheterization After discharge from the hospital for cardiac catheterization, guidelines for self-care include the following: • For the next 24 hours, do not bend at the waist (to lift anything), strain, or lift heavy objects. • Avoid tub baths, but shower as desired. • Talk with your physician about when you may return to work, drive, or resume strenuous activities. • Call your physician if any of the following occur: bleeding, swelling, new bruising or pain from your procedure puncture site, temperature of 101.5°F (38.6°C) or more. • If test results show that you have coronary artery disease, talk with your physician about options for treatment, including cardiac rehabilitation programs in your community. • Talk with your physician and nurse about lifestyle changes to reduce your risk for further or future heart problems, such as quitting smoking, lowering your cholesterol level, initiating dietary changes, beginning an exercise program, or losing weight.
can be induced, (3) to evaluate AV node function, (4) to evaluate the effectiveness of antiarrhythmic medications in suppressing the dysrhythmia, and (5) to determine the need for other therapeutic interventions, such as a pacemaker, implantable cardioverter defibrillator, or radiofrequency ablation (discussed in Chap. 27). EPS is indicated for patients with syncope and/or palpitations and for survivors of cardiac arrest from ventricular fibrillation (sudden cardiac death). The initial study can take up to 4 hours. The patient receives moderate sedation. Catheters with recording and electrical stimulating (pacing) capabilities are inserted into the heart through the femoral and right subclavian veins to record electrical activity in the right and left atrium, bundle of His, and right ventricle. Fluoroscopy guides the positioning of these catheters. Baseline intracardiac recordings are obtained; programmed electrical stimulations of the atrium or ventricle are then administered in an attempt to induce the patient’s dysrhythmia. If the dysrhythmia is induced, various antiarrhythmic medications are administered intravenously. The study is repeated after each medication to evaluate which medication or combination of medications is most effective in controlling the dysrhythmia. After the study, the patient receives an equivalent oral antiarrhythmic agent, and subsequent studies may be necessary to evaluate the effectiveness of that medication. Results of the study may indicate the need for other therapeutic interventions, such as a pacemaker or implantable cardioverter defibrillator. During EPS, lethal dysrhythmias may be induced; therefore, the procedure must be performed in a controlled environment with resuscitation equipment (eg, defibrillator) readily available. Possible complications include bleeding and hematoma from the catheter insertion sites, pneumothorax (air in the pleural cavity that may collapse portions of the lung), deep vein thrombosis, stroke, and sudden death.
Nursing Interventions Patients receive nothing to eat or drink for 8 hours before the procedure. Antiarrhythmic medications are withheld for at least 24 hours before the initial study, and the patient’s cardiac rate
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and rhythm are carefully monitored for dysrhythmias. Other medications may be taken with sips of water. Thorough preparation before EPS will help to minimize patient anxiety. Ensure that the patient understands the reason for the study and is able to describe the common sensations and experiences expected during and after the study. Often the EPS laboratory has relaxation interventions available for patients, such as headsets with music. Also, the patient needs to be aware that the nurses in the EPS laboratory will be monitoring carefully for signs of discomfort and will offer intravenous medications to reduce discomfort or anxiety. Patients should be reminded to request these medications if necessary. Postprocedure interventions include careful monitoring for complications. The nurse takes vital signs, reviews tracings of continuous ECG monitoring, assesses the apical pulse, auscultates for pericardial friction rub (which indicates bleeding into the pericardial sac), and inspects the catheter insertion sites for bleeding or hematoma formation. In addition, the nurse assists the patient to maintain bed rest with the affected extremity kept straight and the head of the bed elevated to 30 degrees for 4 to 6 hours. The frequency of assessments and the duration of bed rest may vary based on institutional policy and physician preference.
HEMODYNAMIC MONITORING Critically ill patients require continuous assessment of their cardiovascular system to diagnose and manage their complex medical conditions. This is most commonly achieved by the use of direct pressure monitoring systems, often referred to as hemodynamic monitoring. Central venous pressure (CVP), pulmonary artery pressure, and intra-arterial BP monitoring are common forms of hemodynamic monitoring. Patients requiring hemodynamic monitoring are cared for in specialty critical care units. Some critical care step-down units also admit stable patients with CVP or intra-arterial BP monitoring. Noninvasive hemodynamic monitoring is used in some facilities. To perform invasive monitoring, specialized equipment is necessary and includes the following:
• A CVP, pulmonary artery, or arterial catheter, which is in-
troduced into the appropriate blood vessel or heart chamber
• A flush system composed of intravenous solution (which
•
• •
may include heparin), tubing, stopcocks, and a flush device, which provides for continuous and manual flushing of the system A pressure bag placed around the flush solution that is maintained at 300 mm Hg of pressure; the pressurized flush system delivers 3 to 5 mL of solution per hour through the catheter to prevent clotting and backflow of blood into the pressure monitoring system A transducer to convert the pressure coming from the artery or heart chamber into an electrical signal An amplifier or monitor, which increases the size of the electrical signal for display on an oscilloscope
Central Venous Pressure Monitoring The CVP, the pressure in the vena cava or right atrium, is used to assess right ventricular function and venous blood return to the right side of the heart. The CVP can be continuously measured by connecting either a catheter positioned in the vena cava or the proximal port of a pulmonary artery catheter to a pressure monitoring system. The pulmonary artery catheter, described in greater
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detail later, is used for critically ill patients. Patients in general medical-surgical units who require CVP monitoring may have a single-lumen or multilumen catheter placed into the superior vena cava. Intermittent measurement of the CVP can then be obtained with the use of a water manometer. Because the pressures in the right atrium and right ventricle are equal at the end of diastole (0 to 8 mm Hg), the CVP is also an indirect method of determining right ventricular filling pressure (preload). This makes the CVP a useful hemodynamic parameter to observe when managing an unstable patient’s fluid volume status. CVP monitoring is most valuable when pressures are monitored over time and are correlated with the patient’s clinical status. A rising pressure may be caused by hypervolemia or by a condition, such as HF, that results in a decrease in myocardial contractility. Pulmonary artery monitoring is preferred for the patient with HF. Decreased CVP indicates reduced right ventricular preload, most often caused by hypovolemia. This diagnosis can be substantiated when a rapid intravenous infusion causes the CVP to rise. (CVP monitoring is not clinically useful in a patient with HF in whom left ventricular failure precedes right ventricular failure, because in these patients an elevated CVP is a very late sign of HF.)
Before insertion of a CVP catheter, the site is prepared by shaving if necessary and by cleansing with an antiseptic solution. A local anesthetic may be used. The physician threads a singlelumen or multilumen catheter through the external jugular, antecubital, or femoral vein into the vena cava just above or within the right atrium. NURSING INTERVENTIONS Once the CVP catheter is inserted, it is secured and a dry, sterile dressing is applied. Catheter placement is confirmed by a chest x-ray, and the site is inspected daily for signs of infection. The dressing and pressure monitoring system or water manometer are changed according to hospital policy. In general, the dressing is to be kept dry and air occlusive. Dressing changes are performed with the use of sterile technique. CVP catheters can be used for infusing intravenous fluids, administering intravenous medications, and drawing blood specimens in addition to monitoring pressure. To measure the CVP, the transducer (when a pressure monitoring system is used) or the zero mark on the manometer (when a water manometer is used) must be placed at a standard reference point, called the phlebostatic axis (Fig. 26-12). After locating this position, the nurse may make an ink mark on the
Fourth intercostal space
45°
1.
20°
A
0° Outermost point of sternum
2. Outermost point of posterior chest
B
Air–fluid interface
C
FIGURE 26-12
Phlebostatic level
The phlebostatic axis and the phlebostatic level. (A) The phlebostatic axis is the crossing of two reference lines: (1) a line from the fourth intercostal space at the point where it joins the sternum, drawn out to the side of the body beneath the axilla; and (2) a line midway between the anterior and posterior surfaces of the chest. (B) The phlebostatic level is a horizontal line through the phlebostatic axis. The air–fluid interface of the stopcock of the transducer, or the zero mark on the manometer, must be level with this axis for accurate measurements. When moving from the flat to erect positions, the patient moves the chest and therefore the reference level; the phlebostatic level stays horizontal through the same reference point. (C) Two methods for referencing the pressure system to the phlebostatic axis. The system can be referenced by placing the air–fluid interface of either the in-line stopcock or stopcock on top of the transducer at the phlebostatic level.
Chapter 26 patient’s chest to indicate the location. If the phlebostatic axis is used, CVP can be measured correctly with the patient supine at any backrest position up to 45 degrees. The range for a normal CVP is 0 to 8 mm Hg with a pressure monitoring system or 3 to 8 cm H2O with a water manometer system. The most common complications of CVP monitoring are infection and air embolism.
Pulmonary Artery Pressure Monitoring Pulmonary artery pressure monitoring is an important tool used in critical care for assessing left ventricular function, diagnosing the etiology of shock, and evaluating the patient’s response to medical interventions (eg, fluid administration, vasoactive medications). Pulmonary artery pressure monitoring is achieved by using a pulmonary artery catheter and pressure monitoring system. Catheters vary in their number of lumens and their types of measurement (eg, cardiac output, oxygen saturation) or pacing capabilities. All types require that a balloon-tipped, flow-directed catheter be inserted into a large vein (usually the subclavian, jugular, or femoral vein); the catheter is then passed into the vena cava and right atrium. In the right atrium, the balloon tip is inflated, and the catheter is carried rapidly by the flow of blood through the tricuspid valve, into the right ventricle, through the pulmonic valve, and into a branch of the pulmonary artery. When the catheter reaches a small pulmonary artery, the balloon is deflated and the catheter is secured with sutures. Fluoroscopy may be used during insertion to visualize the progression of the catheter through the heart chambers to the pulmonary artery. This procedure can be performed in the operating room or cardiac catheterization laboratory or at the bedside in the critical care unit. During insertion of the pulmonary artery catheter, the bedside monitor is observed for waveform and ECG changes as the catheter is moved
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through the heart chambers on the right side and into the pulmonary artery. After the catheter is correctly positioned, the following pressures can be measured: CVP or right atrial pressure, pulmonary artery systolic and diastolic pressures, mean pulmonary artery pressure, and pulmonary artery wedge pressure (Fig. 26-13). If a thermodilution catheter is used, the cardiac output can be measured and systemic vascular resistance and pulmonary vascular resistance can be calculated. Normal pulmonary artery pressure is 25/9 mm Hg, with a mean pressure of 15 mm Hg (see Fig. 26-5 for normal ranges). When the balloon tip is inflated, usually with 1 mL of air, the catheter floats farther out into the pulmonary artery until it becomes wedged. This is an occlusive maneuver that impedes blood flow through that segment of the pulmonary artery. A pressure measurement, called pulmonary artery wedge pressure, is taken within seconds after wedging of the pulmonary artery catheter; then the balloon is immediately deflated and blood flow is restored. The nurse who obtains the wedge reading ensures that the catheter has returned to its normal position in the pulmonary artery by evaluating the pulmonary artery pressure waveform. The pulmonary artery diastolic reading and the wedge pressure reflect the pressure in the ventricle at end-diastole and are particularly important to monitor in critically ill patients, because they are used to evaluate left ventricular filling pressures (preload). At end-diastole, when the mitral valve is open, the wedge pressure is the same as the pressure in the left atrium and the left ventricle, unless the patient has mitral valve disease or pulmonary hypertension. Pulmonary capillary wedge pressure is a mean pressure and is normally 4.5 to 13 mm Hg. Critically ill patients usually require higher left ventricular filling pressures to optimize cardiac output. These patients may need to have their wedge pressure maintained as high as 18 mm Hg.
IV solution in pressure bag
ECG
Monitor PA catheter
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3-way stopcock
Transducer with flush device
Pressure tubing 3-way stopcock
FIGURE 26-13 Example of a pulmonary artery (PA) pressure monitoring system. PA catheter is inserted into the internal jugular vein and advanced into the pulmonary artery.
PA pressure waveform
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NURSING INTERVENTIONS Catheter site care is essentially the same as for a CVP catheter. As in measuring CVP, the transducer must be positioned at the phlebostatic axis to ensure accurate readings (see Fig. 26-12). Complications of pulmonary artery pressure monitoring include infection, pulmonary artery rupture, pulmonary thromboembolism, pulmonary infarction, catheter kinking, dysrhythmias, and air embolism.
Intra-arterial Blood Pressure Monitoring Intra-arterial BP monitoring is used to obtain direct and continuous BP measurements in critically ill patients who have severe hypertension or hypotension (Fig. 26-14). Arterial catheters are also useful when arterial blood gas measurements and blood samples need to be obtained frequently. Once an arterial site is selected (radial, brachial, femoral, or dorsalis pedis), collateral circulation to the area must be confirmed before the catheter is placed. This is a safety precaution to prevent compromised arterial perfusion to the area distal to the arterial catheter insertion site. If no collateral circulation exists and the cannulated artery became occluded, ischemia and infarction of the area distal to that artery could occur. Collateral circulation to the hand can be checked by the Allen test to evaluate the radial and ulnar arteries or by an ultrasonic Doppler test for any of the arteries. With the Allen test, the nurse compresses the radial and ulnar arteries simultaneously and asks the patient to make a fist, causing the hand to blanch. After the patient opens the fist, the nurse releases the pressure on the ulnar artery while maintaining pressure on the radial artery. The patient’s hand will turn pink if the ulnar artery is patent.
IV solution in pressure bag
ECG tracing
Monitor Arterial pressure waveform 3-way stopcock
Transducer with flush device Arterial catheter insertion site
FIGURE 26-14 Example of an arterial pressure monitoring system. The arterial catheter is inserted into the radial artery. A three-way stopcock is used for drawing arterial blood samples.
NURSING INTERVENTIONS Site preparation and care are the same as for CVP catheters. The catheter flush solution is the same as for pulmonary artery catheters. A transducer is attached, and pressures are measured in millimeters of mercury (mm Hg). Complications include local obstruction with distal ischemia, external hemorrhage, massive ecchymosis, dissection, air embolism, blood loss, pain, arteriospasm, and infection.
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Critical Thinking Exercises
1.
You are caring for an elderly man who has had three hospital admissions in 6 months for HF. To plan for his discharge you need to fully understand what is causing these recurrent HF episodes. What medical and nursing history, physical examination, and laboratory data will you need to collect to help you understand the recurrent episodes of HF? What types of information are necessary to help you formulate his plan for discharge? With what other team members might you consult before completing this plan?
2.
While working in a primary care clinic, you notice that many of the patients use tobacco products including cigarettes and chewing tobacco. What are the health risks of tobacco use? The clinic does not have a smoking cessation protocol. You want to help people become tobacco free but have little experience in providing cessation advice. What information and resources will you need to obtain to devise and implement a smoking cessation protocol?
3.
While making a home visit, your patient, a 54-year-old African American woman with a history of hypertension, diabetes, and tobacco use, tells you she has had overwhelming fatigue and right scapular and shoulder pain going down into her arm for the last 10 hours. Describe your rapid chest pain assessment and management plan for this patient. Discuss the factors that may be contributing to her delay in seeking care for symptoms of acute MI. Compare and contrast symptoms of acute MI and factors contributing to delay in seeking care.
REFERENCES AND SELECTED READINGS Books American Heart Association. (2003). Heart and stroke facts: 2002 statistical supplement. Dallas, TX: Author. Apple, S., & Lindsey, J. (1999). Principles and practices of interventional cardiology. Philadelphia: Lippincott Williams & Wilkins. Bickley, L. S., & Sailaygi, P. G. (2003). Bates’ guide to physical examination (8th ed.). Philadelphia: Lippincott Williams & Wilkins. Braunwald, E., Libby, P., & Zipes, D. P. (Eds.). (2001). Heart disease: A textbook of cardiovascular medicine (6th ed.). Philadelphia: W. B. Saunders. Chernecky, C., & Berger, B. (2001). Laboratory tests and diagnostic procedures (3rd ed.). Philadelphia: W. B. Saunders. Darvic, G. (2002). Handbook of hemodynamic monitoring. Invasive and noninvasive clinical application (3rd ed.). Philadelphia: W. B. Saunders. Fuller, J., & Schaller-Ayers, J. (2000). Health assessment: A nursing approach (3rd ed.). Philadelphia: Lippincott Williams & Wilkins. Huff, J. (2001). ECG workout: Exercises in arrhythmia interpretation (4th ed.). Philadelphia: Lippincott Williams & Wilkins. Jairath, N. (1999). Coronary heart disease and risk factor management: A nursing perspective. Philadelphia: W. B. Saunders.
Chapter 26 Kern, M. (2003). The interventional cardiac catheterization handbook (2nd ed.). St. Louis: C. V. Mosby. Maas, M. L., Buckwalter, K. C., Hardy, M. D., Tripp-Reimer, T., Titler, M. G., Specht, J. P., et al. (2001). Nursing care of older adults: Diagnoses, outcomes, and interventions. St. Louis: C. V. Mosby. Miller, C. (1999). Nursing care of older adults: Theory and practice (3rd ed.). Philadelphia: Lippincott Williams & Wilkins. Pohost, G. M., O’Rourke, R. A., Berman, D. S., & Shah, P. M. (2000). Imaging in cardiovascular disease. Philadelphia: Lippincott Williams & Wilkins. Weber, J., & Kelley, J. (2003). Health assessment in nursing (2nd ed.). Philadelphia: Lippincott Williams & Wilkins. Woods, S. L., Froelicher, E. S. S., & Motzer, S. U. (1999). Cardiac nursing (4th ed.). Philadelphia: Lippincott Williams & Wilkins.
Journals Asterisks indicate nursing research articles. Attin, M. (2001). Electrophysiology study: A comprehensive review. American Journal of Critical Care, 10(4), 260–273. *Baim, D., Knopf, W., Hinohara, T., Schwarten, D. E., Schatz, R. A., Pinkerton, C. A., et al. (2000). Suture-mediated closure of the femoral access site after cardiac catheterization: Results of the suture to ambulate and discharge (STAND I and STAND II) trials. American Journal of Cardiology, 85(7), 864–869. Beattie, S. (1999). Cut the risks for cardiac cath patients. RN, 62(1), 50–55. *Bosworth, H., Feaganes, J., Vitaliano, P., Mark, D. B., & Siegler, I. C. (2001). Personality and coping with a common stressor: Cardiac catheterization. Journal of Behavioral Medicine, 24(1), 17–31. *Botti, M., Willianson, B., & Steen, K. (2001). Coronary angiographic observations: Evidence-based or ritualistic practice? Heart & Lung, 30(2), 138–145. Buselli, E. F., & Stuart, E. M. (1999). Influence of psychosocial factors and biopsychosocial interventions on outcomes after myocardial infarction. J Cardiovasc Nurs, 13(3), 60–72. Chyun, D. (2001). Diabetes and coronary heart disease: A time for action. Critical Care Nurse, 21(1), 10–16. Daleiden, A. M., & Schell, H. (2001). Setting a new gold standard: STsegment monitoring provides early detection of myocardial ischemia. American Journal of Nursing, 101, (Suppl.), 4–8, 48–50. Dracup, K., & Cannon, C. (1999). Combination treatment strategies for management of acute myocardial infarction: New directions with current therapies. Critical Care Nurse, 19(4), (Suppl.), 1–17. Drew, B., & Krucoff, M. (1999). Multilead ST-segment monitoring in patients with acute coronary syndromes: A consensus statement for healthcare professionals. ST-segment monitoring practice guidelines international working group. American Journal of Critical Care, 8(6), 372–386. Gibbar-Clements, T., Shirrell, D., Dooley, R., & Smiley, B. (2000). The challenge of warfarin therapy. American Journal of Nursing, 100(3), 38–40. Grundy, S., Howard, B., Smith, S., Jr., Eckel, R., Redberg, R., & Bonow, R. O. (2002). Prevention Conference VI: Diabetes and cardiovascular disease executive summary: Conference proceeding for healthcare professionals from a special writing group of the American Heart Association. Circulation, 105(18), 2231–2239. Hamel, W. (1999). Suppose a Perclose. Progress in Cardiovascular Nursing, 14(4), 136–142. Hinkle, C., & Stegall, G. (2000). Ask the experts: Setting up 15 and 18 lead ECGs. Critical Care Nurse, 20(2), 125–126. Jacobson, C. (2000). Optimum bedside cardiac monitoring. Progress in Cardiovascular Nursing, 15(4), 134–137. *Krantz, D., Santiago, H., & Kop, W. (1999). Prognostic value of mental stress testing in coronary artery disease. American Journal of Cardiology, 84(11), 1292–1297. *Logemann, T., Luetmer, P., Kaliebe, J., Olson, K., & Murdock, D. K. (1999). Two versus six hours of bed rest following left-sided cardiac catheterization and a meta-analysis of early ambulation trials. American Journal of Cardiology, 84(4), 486–488. *Milner, K., Funk, M., Richards, S., Wilmes, R. M., Vaccarino, V., Krumholz, H. M., et al. (1999). Gender differences in symptom pre-
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sentation associated with coronary heart disease. American Journal of Cardiology, 84(4), 396–399. Mosca, L., Collins, P., Herrington, D., Mendelsohn, M. E., Pasternak, R. C., Robertson, R. M., et al. (2001). Hormone replacement therapy and cardiovascular disease: A statement for healthcare professionals from the American Heart Association. Circulation, 104(4), 499–503. Mosca, L., Grungy, S. M., Judelson, D., King, K., Limacher, M., Oparil, S., et al. (1999). AHA/ACC scientific statement: Consensus panel statement. Guide to preventative cardiology for women. American Heart Association/American College of Cardiology. Journal of the American College of Cardiology, 33(6), 1751–1755. *Mott, A. (1999). Psychologic preparation to decrease anxiety associated with cardiac catheterization. Journal of Vascular Nursing, 17(2), 41–49. Pearson, T. A., Blair, S. W., Daniel, S. R., Eckel, R. H., Fair, J. M., Fortmann, S. P., et al. (2002). AHA guidelines for primary prevention of cardiovascular disease and stroke: 2002 update. Consensus panel guide to comprehensive risk reduction for adult patients without coronary or other atherosclerotic vascular diseases. Circulation, 106(3), 388–391. *Richards, S., Funk, M., & Milner, K. (2000). Differences between blacks and whites with coronary heart disease in initial symptoms and delay in seeking care. American Journal of Critical Care, 9(4), 237–244. Robertson, R. (2001). Women and cardiovascular disease: The risk of misperception and the need for action. Circulation, 103(19), 2318–2323. *Roussouw, J. E., Anderson, G. L., Prentice, R. L., LaCroix, A. Z., Kooperberg, C., Stefanick, M. C., et al. (2002). Risk and benefits of estrogen plus progestin in healthy post menopausal women: Principle results from the Women’s Health Initiative randomized controlled trial. Journal of the American Medical Association, 288(3), 321–333. *Schickel, S., Adkisson, P., Miracle, V., Cronin, S. N. (1999). Achieving femoral artery hemostasis after cardiac catheterization: A comparison of methods. American Journal of Critical Care, 8(6), 406–415. Siomko, A. J. (2000). Demystifying cardiac markers. American Journal of Nursing, 100(1), 36–41. Smith, S. C. Jr., Blair, S. N., Bonow, R. O., Brass, L. M., Cerqueira, M. D., Dracup, K., et al. (2001). AHA/ACC guidelines for preventing heart attack and death in patients with atherosclerotic cardiovascular disease. Circulation, 104(13), 1577–1579. Steinke, E. (2000). Sexual counseling: After myocardial infarction. American Journal of Nursing, 100(12), 38–44. The Tobacco Use and Dependence Clinical Practice Guideline Update Panel, Staff, and Consortium Representatives. (2000). A clinical practice guideline for treating tobacco use and dependence: A U.S. Public Health Service Report. Journal of the American Medical Association; 283(24), 3244–3254. *Then, K., Rankin, J., & Fofonoff, D. (2001). Atypical presentation of acute myocardial infarction in 3 age groups. Heart & Lung, 30(4), 285–293. *Wung, S., & Drew, B. (1999). Comparison of 18-lead ECG and selected body surface potential mapping leads in determining maximally deviated ST lead and efficacy in detecting acute myocardial ischemia during coronary occlusion. Journal of Electrophysiology, 32, (Suppl.) 30–37. Zerwic, J. (1999). Patient delay in seeking treatment for acute myocardial infarction symptoms. Journal of Cardiovascular Nursing, 13(3), 21–31.
RESOURCES AND WEBSITES American Heart Association, 7272 Greenville Avenue, Dallas, TX 75231; 1-800-242-8721; http://www.americanheart.org. New York Cardiac Center, 467 Sylvan Avenue, Englewood Cliffs, NJ 07632, 201-569-8180; http://nycardiaccenter.org. Nurse-Beat: Cardiac Nursing Electronic Journal; http://www.nursebeat.com.
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27 ●
Management of Patients With Dysrhythmias and Conduction Problems
LEARNING OBJECTIVES
●
On completion of this chapter, the learner will be able to: 1. Correlate the components of the normal ECG with physiologic 2. 3. 4. 5. 6. 7. 8. 9. 10.
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events of the heart. Define the ECG as a waveform that represents the cardiac electrical event in relation to the lead depicted (placement of electrodes). Analyze elements of an ECG rhythm strip: ventricular and atrial rate, ventricular and atrial rhythm, QRS complex and shape, QRS duration, P wave and shape, PR interval, and P⬊QRS ratio. Identify the ECG criteria, causes, and management of several dysrhythmias, including conduction disturbances. Use the nursing process as a framework for care of patients with dysrhythmias. Compare the different types of pacemakers, their uses, possible complications, and nursing implications. Use the nursing process as a framework for care of patients with pacemakers. Describe the key points of using a defibrillator. Describe the purpose of an implantable cardioverter defibrillator (ICD), the types available, and the nursing implications. Describe invasive methods to diagnose and treat recurrent dysrhythmias, and discuss the nursing implications.
W
Chapter 27
Management of Patients With Dysrhythmias and Conduction Problems
ithout a regular rate and rhythm, the heart may not perform efficiently as a pump to circulate oxygenated blood and other life-sustaining nutrients to all the body organs (including itself) and tissues. With an irregular or erratic rhythm, the heart is considered to be dysrhythmic (sometimes called arrhythmic). This has the potential to be a dangerous condition.
Dysrhythmias Dysrhythmias are disorders of the formation or conduction (or both) of the electrical impulse within the heart. These disorders can cause disturbances of the heart rate, the heart rhythm, or both. Dysrhythmias may initially be evidenced by the hemodynamic effect they cause (eg, a change in conduction may change the pumping action of the heart and cause decreased blood pressure). Dysrhythmias are diagnosed by analyzing the electrocardiographic waveform. They are named according to the site of origin of the impulse and the mechanism of formation or conduction involved (Chart 27-1). For example, an impulse that originates in the sinoatrial (SA) node and that has a slow rate is called sinus bradycardia.
NORMAL ELECTRICAL CONDUCTION The electrical impulse that stimulates and paces the cardiac muscle normally originates in the sinus node (SA node), an area located near the superior vena cava in the right atrium. Usually, the electrical impulse occurs at a rate ranging between 60 and 100 times a minute in the adult. The electrical impulse quickly travels from the sinus node through the atria to the atrioventricular (AV) node (Fig. 27-1). The electrical stimulation of the muscle cells of the atria causes them to contract. The structure of the AV node slows the electrical impulse, which allows time for the atria to contract and fill the ventricles with blood before the electrical impulse
Chart 27-1
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Identifying Dysrhythmias
Sites of Origin Sinus (SA) node Atria Atrioventricular (AV) node or junction Ventricles Mechanisms of Formation or Conduction Normal (idio) rhythm Bradycardia Tachycardia Dysrhythmia Flutter Fibrillation Premature complexes Blocks
travels very quickly through the bundle of His to the right and left bundle branches and the Purkinje fibers, located in the ventricular muscle. The electrical stimulation of the muscle cells of the ventricles, in turn, causes the mechanical contraction of the ventricles (systole). The cells repolarize and the ventricles then relax (diastole). The process from sinus node electrical impulse generation through ventricular repolarization completes the electromechanical circuit, and the cycle begins again. Sinus rhythm promotes cardiovascular circulation. The electrical impulse causes (and, therefore, is followed by) the mechanical contraction of the heart muscle. The electrical stimulation is called depolarization; the mechanical contraction is called systole. Electrical relaxation is called repolarization and mechanical relaxation is called diastole. See Chapter 26 for a more complete explanation of cardiac function.
Glossary ablation: purposeful destruction of heart muscle cells, usually in an attempt to control a dysrhythmia antiarrhythmic: a medication that suppresses or prevents a dysrhythmia automaticity: ability of the cardiac muscle to initiate an electrical impulse cardioversion: electrical current administered in synchrony with the patient’s own QRS to stop a dysrhythmia conductivity: ability of the cardiac muscle to transmit electrical impulses defibrillation: electrical current administered to stop a dysrhythmia, not synchronized with the patient’s QRS complex depolarization: process by which cardiac muscle cells change from a more negatively charged to a more positively charged intracellular state dysrhythmia (also referred to as arrhythmia): disorder of the formation or conduction (or both) of the electrical impulse within the heart, altering the heart rate, heart rhythm, or both and potentially causing altered blood flow
implantable cardioverter defibrillator (ICD): a device implanted into the chest to treat dysrhythmias inhibited: in reference to pacemakers, term used to describe the pacemaker withholding an impulse (not firing) P wave: the part of an electrocardiogram (ECG) that reflects conduction of an electrical impulse through the atrium; atrial depolarization paroxysmal: a dysrhythmia that has a sudden onset and/or termination and is usually of short duration PR interval: the part of an ECG that reflects conduction of an electrical impulse from the sinoatrial (SA) node through the atrioventricular (AV) node proarrhythmic: an agent (eg, a medication) that causes or exacerbates a dysrhythmia QRS complex: the part of an ECG that reflects conduction of an electrical impulse through the ventricles; ventricular depolarization QT interval: the part of an ECG that reflects the time from ventricular depolarization to repolarization
repolarization: process by which cardiac muscle cells return to a more negatively charged intracellular condition, their resting state sinus rhythm: electrical activity of the heart initiated by the sinoatrial (SA) node ST segment: the part of an ECG that reflects the end of ventricular depolarization (end of the QRS complex) through ventricular repolarization (end of the T wave) supraventricular tachycardia (SVT): a rhythm that originates in the conduction system above the ventricles T wave: the part of an ECG that reflects repolarization of the ventricles triggered: in reference to pacemakers, term used to describe the release of an impulse in response to some stimulus U wave: the part of an ECG that may reflect Purkinje fiber repolarization; usually seen when a patient’s serum potassium level is low ventricular tachycardia (VT): a rhythm that originates in the ventricles
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Lead I
– –
+ –
SA node
Left atrium
Right atrium AV node
Bundle of His Left ventricle
Right ventricle
Right bundle
Lead I Left bundle
II
Le
ad
ad
Le
III
Purkinje fibers
+
+
Lead II
Lead III
FIGURE 27-1
Relationship of electrocardiogram (ECG) complex, lead system, and electrical impulse. The heart conducts electrical activity, which the ECG measures and shows. The configurations of electrical activity displayed on the ECG vary depending on the lead (or view) of the ECG and on the rhythm of the heart. Therefore, the configuration of a normal rhythm tracing from lead I will differ from the configuration of a normal rhythm tracing from lead II, lead II will differ from lead III, and so on. The same is true for abnormal rhythms and cardiac disorders. To make an accurate assessment of the heart’s electrical activity or to identify where, when, and what abnormalities occur, the ECG needs to be evaluated from every lead, not just from lead II. Here the different areas of electrical activity are identified by color.
Influences on Heart Rate and Contractility The heart rate is influenced by the autonomic nervous system, which consists of sympathetic and parasympathetic fibers. Sympathetic nerve fibers (also referred to as adrenergic fibers) are attached to the heart and arteries as well as several other areas in the body. Stimulation of the sympathetic system increases heart rate (positive chronotropy), conduction through the AV node (positive dromotropy), and the force of myocardial contraction (positive inotropy). Sympathetic stimulation also constricts peripheral blood vessels, therefore increasing blood pressure. Parasympathetic nerve fibers are also attached to the heart and arteries. Parasympathetic stimulation reduces the heart rate (negative chronotropy), AV conduction (negative dromotropy), and the force of atrial myocardial contraction. The decreased sympathetic stimulation results in dilation of arteries, thereby lowering blood pressure.
Manipulation of the autonomic nervous system may increase or decrease the incidence of dysrhythmias. Increased sympathetic stimulation—caused, for example, by exercise, anxiety, fever, or administration of catecholamines (eg, dopamine [Intropin], aminophylline, dobutamine [Dobutrex])—may increase the incidence of dysrhythmias. Decreased sympathetic stimulation (eg, with rest, anxiety-reduction methods such as therapeutic communication or prayer, administration of beta-adrenergic blocking agents) may decrease the incidence of dysrhythmias.
INTERPRETATION OF THE ELECTROCARDIOGRAM The electrical impulse that travels through the heart can be viewed by means of electrocardiography, the end product of which is an electrocardiogram (ECG). Each phase of the cardiac cycle is re-
Chapter 27
Management of Patients With Dysrhythmias and Conduction Problems
flected by specific waveforms on the screen of a cardiac monitor or on a strip of ECG graph paper. An ECG is obtained by slightly abrading the skin with a clean dry gauze pad and placing electrodes on the body at specific areas. Electrodes come in various shapes and sizes, but all have two components: (1) an adhesive substance that attaches to the skin to secure the electrode in place and (2) a substance that reduces the skin’s electrical impedance and promotes detection of the electrical current. The number and placement of the electrodes depend on the type of ECG needed. Most continuous monitors use two to five electrodes, usually placed on the limbs and the chest. These electrodes create an imaginary line, called a lead, that serves as a reference point from which the electrical activity is viewed. A lead is like an eye of a camera; it has a narrow peripheral field of vision, looking only at the electrical activity directly in front of it. Therefore, the ECG waveforms that appear on the paper or cardiac monitor represent the electrical current in relation to the lead (see Fig. 27-1). A change in the waveform can be caused by a change in the electrical current (where it originates or how it is conducted) or by a change in the lead.
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Supplemental right precordial leads
V5R
V4R V3R V2R V1R
Mid-clavicle Anterior axillary line Horizontal plane of V4–V6 RA
LA
Obtaining an Electrocardiogram V1 V2 V3 V4 V5
Electrodes are attached to cable wires, which are connected to one of the following:
• An ECG machine placed at the patient’s side for an immediate recording (standard 12-lead ECG)
• A cardiac monitor at the patient’s bedside for continuous • •
reading; this kind of monitoring, usually called hardwire monitoring, is associated with intensive care units A small box that the patient carries and that continuously transmits the ECG information by radio waves to a central monitor located elsewhere (called telemetry) A small, lightweight tape recorder-like machine (called a Holter monitor) that the patient wears and that continuously records the ECG on a tape, which is later viewed and analyzed with a scanner
The placement of electrodes for continuous monitoring, telemetry, or Holter monitoring varies with the type of technology that is appropriate and available, the purpose of monitoring, and the standards of the institution. For a standard 12-lead ECG, 10 electrodes (six on the chest and four on the limbs) are placed on the body (Fig. 27-2). To prevent interference from the electrical activity of skeletal muscle, the limb electrodes are usually placed on areas that are not bony and that do not have significant movement. These limb electrodes provide the first six leads: leads I, II, III, aVR, aVL, and aVF. The six chest electrodes are attached to the chest at very specific areas. The chest electrodes provide the V or precordial leads, V1 through V6. To locate the fourth intercostal space and the placement of V1, locate the sternal angle and then the sternal notch, which is about 1 or 2 inches below the sternal angle. When the fingers are moved to the patient’s immediate right, the second rib can be palpated. The second intercostal space is the indentation felt just below the second rib. Locating the specific intercostal space is critical for correct chest electrode placement. Errors in diagnosis can occur if electrodes are incorrectly placed. Sometimes, when the patient is in the hospital and needs to be monitored closely for ECG changes, the chest electrodes are left in place to ensure the same placement for follow-up ECGs. A standard 12-lead ECG reflects the electrical activity primarily in the left ventricle. Placement of additional electrodes for
ECG strip
ECG machine RL
LL
FIGURE 27-2
ECG electrode placement. The standard left precordial leads are V1—4th intercostal space, right sternal border; V2—4th intercostal space, left sternal border; V3—diagonally between V2 and V4; V4—5th intercostal space, left midclavicular line; V5 —same level as V4, anterior axillary line; V6 (not illustrated)—same level as V4 and V5, midaxillary line. The right precordial leads, placed across the right side of the chest, are the mirror opposite of the left leads. Adapted from Hosley, J. B., & Molle-Matthews, E. (1999). Lippincott’s pocket guide to medical assisting. Philadelphia: Lippincott Williams & Wilkins.
other leads may be needed to obtain more complete information. For example, in patients with suspected right-sided heart damage, right-sided precordial leads are required to evaluate the right ventricle (see Fig. 27-2).
Analysis of the Electrocardiogram The ECG waveform represents the function of the heart’s conduction system, which normally initiates and conducts the electrical activity, in relation to the lead. When analyzed accurately, the ECG offers important information about the electrical activity
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of the heart. ECG waveforms are printed on graph paper that is divided by light and dark vertical and horizontal lines at standard intervals (Fig. 27-3). Time and rate are measured on the horizontal axis of the graph, and amplitude or voltage is measured on the vertical axis. When an ECG waveform moves toward the top of the paper, it is called a positive deflection. When it moves toward the bottom of the paper, it is called a negative deflection. When reviewing an ECG, each waveform should be examined and compared with the others.
The U wave is thought to represent repolarization of the Purkinje fibers, but it sometimes is seen in patients with hypokalemia (low potassium levels), hypertension, or heart disease. If present, the U wave follows the T wave and is usually smaller than the P wave. If tall, it may be mistaken for an extra P wave. The PR interval is measured from the beginning of the P wave to the beginning of the QRS complex and represents the time needed for sinus node stimulation, atrial depolarization, and conduction through the AV node before ventricular depolarization. In adults, the PR interval normally ranges from 0.12 to 0.20 seconds in duration. The ST segment, which represents early ventricular repolarization, lasts from the end of the QRS complex to the beginning of the T wave. The beginning of the ST segment is usually identified by a change in the thickness or angle of the terminal portion of the QRS complex. The end of the ST segment may be more difficult to identify because it merges into the T wave. The ST segment is normally isoelectric (see discussion of TP interval). It is analyzed to identify whether it is above or below the isoelectric line, which may be, among other signs and symptoms, a sign of cardiac ischemia (see Chap. 28). The QT interval, which represents the total time for ventricular depolarization and repolarization, is measured from the beginning of the QRS complex to the end of the T wave. The QT interval varies with heart rate, gender, and age, and the measured interval needs to be corrected for these variables through a specific calculation. Several ECG interpretation books contain charts of these calculations. The QT interval is usually 0.32 to 0.40 seconds in duration if the heart rate is 65 to 95 beats per minute. If the QT interval becomes prolonged, the patient may be at risk for a lethal ventricular dysrhythmia called torsades de pointes. The TP interval is measured from the end of the T wave to the beginning of the next P wave, an isoelectric period (see Fig 27-3).
WAVES, COMPLEXES, AND INTERVALS The ECG is composed of waveforms (including the P wave, the QRS complex, the T wave, and possibly a U wave) and of segments or intervals (including the PR interval, the ST segment, and the QT interval) (see Fig. 27-3). The P wave represents the electrical impulse starting in the sinus node and spreading through the atria. Therefore, the P wave represents atrial muscle depolarization. It is normally 2.5 mm or less in height and 0.11 second or less in duration. The QRS complex represents ventricular muscle depolarization. Not all QRS complexes have all three waveforms. The first negative deflection after the P wave is the Q wave, which is normally less than 0.04 second in duration and less than 25% of the R wave amplitude; the first positive deflection after the P wave is the R wave; and the S wave is the first negative deflection after the R wave. When a wave is less than 5 mm in height, small letters (q, r, s) are used; when a wave is taller than 5 mm, capital letters (Q, R, S) are used. The QRS complex is normally less than 0.12 seconds in duration. The T wave represents ventricular muscle repolarization (when the cells regain a negative charge; also called the resting state). It follows the QRS complex and is usually the same direction as the QRS complex.
5 mm 0.5 mV
5 mm 0.2 sec
P-R
S-T
P-R
S-T
seg
seg
seg
seg
P
TP interval
P-R interval
T
P
U
TP interval
QRS
P-R interval
U
QRS
Q-T interval
FIGURE 27-3
T
ECG graph and commonly measured components. Each small box represents 0.04 seconds on the horizontal axis and 1 mm or 0.1 millivolt on the vertical axis. The PR interval is measured from the beginning of the P wave to the beginning of the QRS complex; the QRS complex is measured from the beginning of the Q wave to the end of the S wave; the QT interval is measured from the beginning of the Q wave to the end of the T wave; and the TP interval is measured from the end of the T wave to the beginning of the next P wave.
Q-T interval
Chapter 27
Management of Patients With Dysrhythmias and Conduction Problems
When no electrical activity is detected, the line on the graph remains flat; this is called the isoelectric line. The ST segment is compared with the TP interval to detect changes from the line on the graph during the isoelectric period. The PP interval is measured from the beginning of one P wave to the beginning of the next. The PP interval is used to determine atrial rhythm and atrial rate. The RR interval is measured from one QRS complex to the next QRS complex. The RR interval is used to determine ventricular rate and rhythm (Fig. 27-4). DETERMINING VENTRICULAR HEART RATE FROM THE ELECTROCARDIOGRAM Heart rate can be obtained from the ECG strip by several methods. A 1-minute strip contains 300 large boxes and 1500 small boxes. Therefore, an easy and accurate method of determining heart rate with a regular rhythm is to count the number of small boxes within an RR interval and divide 1500 by that number. If, for example, there are 10 small boxes between two R waves, the heart rate is 1500 ÷ 10, or 150; if there are 25 small boxes, the heart rate is 1500 ÷ 25, or 60 (see Fig. 27-4A). An alternative but less accurate method for estimating heart rate, which is usually used when the rhythm is irregular, is to count the number of RR intervals in 6 seconds and multiply that number by 10. The top of the ECG paper is usually marked at 3-second intervals, which is 15 large boxes horizontally (see Fig. 27-4B). The RR intervals are counted, rather than QRS complexes, because a computed heart rate based on the latter might be inaccurately high. The same methods may be used for determining atrial rate, using the PP interval instead of the RR interval. DETERMINING HEART RHYTHM FROM THE ELECTROCARDIOGRAM The rhythm is often identified at the same time the rate is determined. The RR interval is used to determine ventricular rhythm and the PP interval to determine atrial rhythm. If the intervals are the same or nearly the same throughout the strip, the rhythm is
P
to
called regular. If the intervals are different, the rhythm is called irregular.
ANALYZING THE ELECTROCARDIOGRAM RHYTHM STRIP The ECG must be analyzed in a systematic manner to determine the patient’s cardiac rhythm and to detect dysrhythmias and conduction disorders, as well as evidence of myocardial ischemia, injury, and infarction. Chart 27-2 is an example of a method that can be used to analyze the patient’s rhythm. Once the rhythm has been analyzed, the findings are compared with and matched to the ECG criteria for dysrhythmias to determine a diagnosis. It is important for the nurse to assess the patient to determine the physiologic effect of the dysrhythmia and to identify possible causes. Treatment of dysrhythmias is based on the etiology and the effect of the dysrhythmia, not on its presence alone.
Normal Sinus Rhythm Normal sinus rhythm occurs when the electrical impulse starts at a regular rate and rhythm in the sinus node and travels through the normal conduction pathway. The following are the ECG criteria for normal sinus rhythm (Fig. 27-5): Ventricular and atrial rate: 60 to 100 in the adult Ventricular and atrial rhythm: Regular QRS shape and duration: Usually normal, but may be regularly abnormal P wave: Normal and consistent shape; always in front of the QRS PR interval: Consistent interval between 0.12 and 0.20 seconds P: QRS ratio: 1⬊1
Types of Dysrhythmias Dysrhythmias include sinus node, atrial, junctional, and ventricular dysrhythmias and their various subcategories.
P
R
to
R
6 seconds 3 seconds
FIGURE 27-4
687
3 seconds
(A) Heart rate determination for a regular rhythm: 1500 divided by the number of small boxes between two R waves (there are 25 in this example) equals the ventricular heart rate. The heart rate in this example is 60. (B) Heart rate determination if the rhythm is irregular. There are approximately seven RR intervals in 6 seconds. Seven times 10 equals 70. The heart rate is 70.
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Chart 27-2
CARDIOVASCULAR, CIRCULATORY, AND HEMATOLOGIC FUNCTION
Interpreting Dysrhythmias: Systematic Analysis of the Electrocardiogram
When examining an ECG rhythm strip to learn more about a patient’s dysrhythmia, the nurse conducts the following assessment: 1. Determine the ventricular rate. 2. Determine the ventricular rhythm. 3. Determine QRS duration. 4. Determine whether the QRS duration is consistent throughout the strip. If not, identify other duration. 5. Identify QRS shape; if not consistent, then identify other shapes. 6. Identify P waves; is there a P in front of every QRS? 7. Identify P-wave shape; identify whether it is consistent or not. 8. Determine the atrial rate. 9. Determine the atrial rhythm. 10. Determine each PR interval. 11. Determine if the PR intervals are consistent, irregular but with a pattern to the irregularity, or just irregular. 12. Determine how many P waves for each QRS (P⬊QRS ratio). In many cases, the nurse may use a checklist and document the findings next to the appropriate ECG criterion.
SINUS NODE DYSRHYTHMIAS Sinus Bradycardia. Sinus bradycardia occurs when the sinus node creates an impulse at a slower-than-normal rate. Causes include lower metabolic needs (eg, sleep, athletic training, hypothermia, hypothyroidism), vagal stimulation (eg, from vomiting, suctioning, severe pain, extreme emotions), medications (eg, calcium channel blockers, amiodarone, beta-blockers), increased intracranial pressure, and myocardial infarction (MI), especially of the inferior wall. The following are characteristics of sinus bradycardia (Fig. 27-6): Ventricular and atrial rate: Less than 60 in the adult Ventricular and atrial rhythm: Regular QRS shape and duration: Usually normal, but may be regularly abnormal P wave: Normal and consistent shape; always in front of the QRS PR interval: Consistent interval between 0.12 and 0.20 seconds P: QRS ratio: 1⬊1 All characteristics of sinus bradycardia are the same as those of normal sinus rhythm, except for the rate. The patient is assessed to determine the hemodynamic effect and the possible cause of the dysrhythmia. If the decrease in heart rate results from stimulation of the vagus nerve, such as with bearing down during defecation or vomiting, attempts are made to prevent further vagal
FIGURE 27-5
Normal sinus rhythm in lead II.
stimulation. If the bradycardia is from a medication such as a beta-blocker, the medication may be withheld. If the slow heart rate causes significant hemodynamic changes, resulting in shortness of breath, decreased level of consciousness, angina, hypotension, ST-segment changes, or premature ventricular complexes, treatment is directed toward increasing the heart rate. Atropine, 0.5 to 1.0 mg given rapidly as an intravenous (IV) bolus, is the medication of choice in treating sinus bradycardia. It blocks vagal stimulation, thus allowing a normal rate to occur. Rarely, catecholamines and emergency transcutaneous pacing also may be implemented. Sinus Tachycardia. Sinus tachycardia occurs when the sinus node creates an impulse at a faster-than-normal rate. It may be caused by acute blood loss, anemia, shock, hypervolemia, hypovolemia, congestive heart failure, pain, hypermetabolic states, fever, exercise, anxiety, or sympathomimetic medications. The ECG criteria for sinus tachycardia follow (Fig. 27-7): Ventricular and atrial rate: Greater than 100 in the adult Ventricular and atrial rhythm: Regular QRS shape and duration: Usually normal, but may be regularly abnormal P wave: Normal and consistent shape; always in front of the QRS, but may be buried in the preceding T wave PR interval: Consistent interval between 0.12 and 0.20 seconds P: QRS ratio: 1⬊1 All aspects of sinus tachycardia are the same as those of normal sinus rhythm, except for the rate. As the heart rate increases, the diastolic filling time decreases, possibly resulting in reduced cardiac output and subsequent symptoms of syncope and low blood pressure. If the rapid rate persists and the heart cannot compensate for the decreased ventricular filling, the patient may develop acute pulmonary edema. Treatment of sinus tachycardia is usually directed at abolishing its cause. Calcium channel blockers and beta-blockers (Table 27-1) may be used to reduce the heart rate quickly. Sinus Arrhythmia. Sinus arrhythmia occurs when the sinus node creates an impulse at an irregular rhythm; the rate usually increases with inspiration and decreases with expiration. Nonrespiratory causes include heart disease and valvular disease, but these are rarely seen. The ECG criteria for sinus arrhythmia follow (Fig. 27-8): Ventricular and atrial rate: 60 to 100 in the adult Ventricular and atrial rhythm: Irregular QRS shape and duration: Usually normal, but may be regularly abnormal
Chapter 27
FIGURE 27-6
Management of Patients With Dysrhythmias and Conduction Problems
Sinus bradycardia in lead II.
P wave: Normal and consistent shape; always in front of the QRS PR interval: Consistent interval between 0.12 and 0.20 seconds P: QRS ratio: 1⬊1 Sinus arrhythmia does not cause any significant hemodynamic effect and usually is not treated. ATRIAL DYSRHYTHMIAS Premature Atrial Complex. A premature atrial complex (PAC) is a single ECG complex that occurs when an electrical impulse starts in the atrium before the next normal impulse of the sinus node. The PAC may be caused by caffeine, alcohol, nicotine, stretched atrial myocardium (as in hypervolemia), anxiety, hypokalemia (low potassium level), hypermetabolic states, or atrial ischemia, injury, or infarction. PACs are often seen with sinus tachycardia. PACs have the following characteristics (Fig. 27-9): Ventricular and atrial rate: Depends on the underlying rhythm (eg, sinus tachycardia) Ventricular and atrial rhythm: Irregular due to early P waves, creating a PP interval that is shorter than the others. This is sometimes followed by a longer-than-normal PP interval, but one that is less than twice the normal PP interval. This type of interval is called a noncompensatory pause. QRS shape and duration: The QRS that follows the early P wave is usually normal, but it may be abnormal (aberrantly conducted PAC). It may even be absent (blocked PAC). P wave: An early and different P wave may be seen or may be hidden in the T wave; other P waves in the strip are consistent. PR interval: The early P wave has a shorter-than-normal PR interval, but still between 0.12 and 0.20 seconds. P: QRS ratio: usually 1⬊1
FIGURE 27-7
689
Sinus tachycardia in lead II.
PACs are common in normal hearts. The patient may say, “My heart skipped a beat.” A pulse deficit (a difference between the apical and radial pulse rate) may exist. If PACs are infrequent, no treatment is necessary. If they are frequent (more than 6 per minute), this may herald a worsening disease state or the onset of more serious dysrhythmias, such as atrial fibrillation. Treatment is directed toward the cause. Atrial Flutter. Atrial flutter occurs in the atrium and creates impulses at an atrial rate between 250 and 400 times per minute. Because the atrial rate is faster than the AV node can conduct, not all atrial impulses are conducted into the ventricle, causing a therapeutic block at the AV node. This is an important feature of this dysrhythmia. If all atrial impulses were conducted to the ventricle, the ventricular rate would also be 250 to 400, which would result in ventricular fibrillation, a life-threatening dysrhythmia. Causes are similar to that of atrial fibrillation. Atrial flutter is characterized by the following (Fig. 27-10): Ventricular and atrial rate: Atrial rate ranges between 250 and 400; ventricular rate usually ranges between 75 and 150. Ventricular and atrial rhythm: The atrial rhythm is regular; the ventricular rhythm is usually regular but may be irregular because of a change in the AV conduction. QRS shape and duration: Usually normal, but may be abnormal or may be absent P wave: Saw-toothed shape. These waves are referred to as F waves. PR interval: Multiple F waves may make it difficult to determine the PR interval. P: QRS ratio: 2⬊1, 3⬊1, or 4⬊1 Atrial flutter can cause serious signs and symptoms, such as chest pain, shortness of breath, and low blood pressure. If the
Unit 6
690
Table 27-1
CARDIOVASCULAR, CIRCULATORY, AND HEMATOLOGIC FUNCTION
• Summary of Antiarrhythmic Medications*
CLASS
ACTION
DRUGS: GENERIC (TRADE) NAMES
SIDE EFFECTS
NURSING INTERVENTIONS
1A
Moderate depression of depolarization; prolongs repolarization Treats and prevents atrial and ventricular dysrhythmias
quinidine (Quinaglute, Quinalan, Quinora, Quinidex, Cardioquin) procainamide (Pronestyl) disopyramide (Norpace)
Decreased cardiac contractility Prolonged QRS, QT Proarrhythmic Hypotension with IV administration Lupus-like syndrome with Pronestyl Anticholinergic effects: dry mouth, decreased urine output
1B
Minimal depression of depolarization; shortened repolarization Treats ventricular dysrhythmias Marked depression of depolarization; little effect on repolarization Treats atrial and ventricular dysrhythmias Decreases automaticity and conduction Treats atrial and ventricular dysrhythmias
lidocaine (Xylocaine) mexiletine (Mexitil) tocainide (Tonocard)
CNS changes (eg, confusion, lethargy)
Observe for HF Monitor BP with IV administration Monitor QRS duration for increase >50% from baseline Monitor for prolonged QT Monitor N-acetyl procainamide (NAPA) laboratory values during procainamide therapy Discuss with physician decreasing the dose in elderly patients and patients with cardiac/liver dysfunction
flecainide (Tambocor) propafenone (Rhythmol)
Proarrhythmic HF Bradycardia AV blocks
Discuss patient’s left ventricular function with physician
acebutolol (Sectral) atenolol (Tenormin) esmolol (Brevibloc) labetalol (Normodyne) metoprolol (Lopressor, Toprol) nadolol (Corgard) propranolol (Betachron E-R, Inderal) sotalol (Betapace; also has class III actions) amiodarone (Cordarone, Pacerone) dofetilide (Tikosyn) ibutilide (Corvert)
Bradycardia, AV block Decreased contractility Bronchospasm Hypotension with IV administration Masks hypoglycemia and thyrotoxicosis CNS disturbances
Monitor heart rate, PR interval, signs and symptoms of HF Monitor blood glucose level in patients with type 2 diabetes mellitus
Pulmonary toxicity (amiodarone) Corneal microdeposits (amiodarone) Photosensitivity (amiodarone) Hypotension with IV administration Polymorphic ventricular dysrhythmias Nausea and vomiting See beta-blockers (sotolol) Bradycardia, AV blocks Hypotension with IV administration HF, peripheral edema
Make sure patient is sent for baseline pulmonary function tests (amiodarone) Closely monitor patient
1C
II
III
Prolongs repolarization Primarily treats and prevents ventricular dysrhythmias; may also be used to treat atrial dysrhythmias
IV
Blocks calcium channel Treats atrial dysrhythmias
verapamil (Calan, Isoptin, Verlan) diltiazem (Cardizem, Dilacor, Tiazac)
*Based on Vaughn-Williams classification. AV, atrioventricular; BP, blood pressure; CNS, central nervous system; HF, heart failure; IV, intravenous.
FIGURE 27-8
Sinus arrhythmia in lead II.
Monitor heart rate, PR interval Monitor blood pressure closely with IV administration Monitor for signs and symptoms of HF
Chapter 27
*
normal PP interval
shorter PP interval
Management of Patients With Dysrhythmias and Conduction Problems
*
longer PP interval
*
*
691
*
= PAC
noncompensatory pause
FIGURE 27-9 Premature atrial complexes (PACs) in lead II. Note pause following PAC that is longer than the normal PP interval, but shorter than twice the normal PP interval. patient is unstable, electrical cardioversion (discussed later) is usually indicated. If the patient is stable, diltiazem (eg, Cardizem), verapamil (eg, Calan, Isoptin), beta-blockers, or digitalis may be administered intravenously to slow the ventricular rate. These medications can slow conduction through the AV node. Flecainide (Tambocor), ibutilide (Corvert), dofetilide (Tikosyn), quinidine (eg, Cardioquin, Quinaglute), disopyramide (Norpace), or amiodarone (Cordarone, Pacerone) may be given to promote conversion to sinus rhythm (see Table 27-1). If medication therapy is unsuccessful, electrical cardioversion is often successful. Once conversion has occurred, quinidine, disopyramide, flecainide, propafenone (Rhythmol), amiodarone, or sotalol (Betapace) may be given to maintain sinus rhythm (see Table 27-1). Atrial Fibrillation. Atrial fibrillation causes a rapid, disorganized, and uncoordinated twitching of atrial musculature. It is the most common dysrhythmia that causes patients to seek medical attention. It may start and stop suddenly. Atrial fibrillation may occur for a very short time (paroxysmal), or it may be chronic. Atrial fibrillation is usually associated with advanced age, valvular heart disease, coronary artery disease, hypertension, cardiomyopathy, hyperthyroidism, pulmonary disease, acute moderate to heavy ingestion of alcohol (“holiday heart” syndrome), or the aftermath of open heart surgery. Sometimes it occurs in people without any underlying pathophysiology (termed lone atrial fibrillation). Atrial fibrillation is characterized by the following (Fig. 27-11):
FIGURE 27-10
Atrial flutter in lead II.
Ventricular and atrial rate: Atrial rate is 300 to 600. Ventricular rate is usually 120 to 200 in untreated atrial fibrillation Ventricular and atrial rhythm: Highly irregular QRS shape and duration: Usually normal, but may be abnormal P wave: No discernible P waves; irregular undulating waves are seen and are referred to as fibrillatory or f waves PR interval: Cannot be measured P: QRS ratio: many⬊1 A rapid ventricular response reduces the time for ventricular filling, resulting in a smaller stroke volume. Because this rhythm causes the atria and ventricles to contract at different times, the atrial kick (the last part of diastole and ventricular filling, which accounts for 25% to 30% of the cardiac output) is also lost. This leads to symptoms of irregular palpitations, fatigue, and malaise. There is usually a pulse deficit, a numerical difference between apical and radial pulse rates. The shorter time in diastole reduces the time available for coronary artery perfusion, thereby increasing the risk for myocardial ischemia. The erratic atrial contraction promotes the formation of a thrombus within the atria, increasing the risk for an embolic event. There is a two- to five-fold increase in the risk of stroke (brain attack). Treatment of atrial fibrillation depends on its cause and duration and the patient’s symptoms, age, and comorbidities. In many patients, atrial fibrillation converts to sinus rhythm within 24 hours and without treatment. Both stable and unstable atrial fibrillation
Unit 6
692
FIGURE 27-11
CARDIOVASCULAR, CIRCULATORY, AND HEMATOLOGIC FUNCTION
Atrial fibrillation in lead II.
of short duration are treated the same as stable and unstable atrial flutter. Cardioversion may be indicated for atrial fibrillation that has been present for less than 48 hours, a condition termed acuteonset atrial fibrillation. Cardioversion of atrial fibrillation that has lasted longer than 48 hours should be avoided unless the patient has received anticoagulants, due to the high risk for embolization of atrial thrombi. For atrial fibrillation of acute onset, the medications quinidine, ibutilide, flecainide, dofetilide, propafenone, procainamide (Pronestyl), disopyramide, or amiodarone (see Table 27-1) may be given to achieve conversion to sinus rhythm (McNamara et al., 2001). Intravenous adenosine (Adenocard, Adenoscan) has also been used for conversion, as well as to assist in the diagnosis. To prevent recurrence and to maintain sinus rhythm, quinidine, disopyramide, flecainide, propafenone, sotalol, or amiodarone may be prescribed. Calcium-channel blockers [diltiazem (Cardizem, Dilacor, Tiazac) and verapamil (Calan, Isoptin, Verelan)] and beta blockers (see Table 27-1) are effective in controlling the ventricular rate in atrial fibrillation, especially during exercise (McNamara, et al., 2001). Use of digoxin is recommended to control the ventricular rate in those patients with poor cardiac function (ejection fraction less than 40%) (Hauptman & Kelly, 1999). In addition, warfarin is indicated if the patient is at higher risk for a stroke (ie, is elderly or has hypertension, heart failure, or a history of stroke). Aspirin may be substituted for warfarin for those with contraindications to warfarin and those who are at lower risk of stroke. The choice of antithrombotic medication can be guided by transesophageal echocardiography. Pacemaker implantation or surgery is sometimes indicated for patients who are unresponsive to medications.
FIGURE 27-12
Junctional rhythm in lead II; note short PR intervals.
JUNCTIONAL DYSRHYTHMIAS Premature Junctional Complex. A premature junctional complex is an impulse that starts in the AV nodal area before the next normal sinus impulse reaches the AV node. Premature junctional complexes are less common than PACs. Causes of premature junctional complex include digitalis toxicity, congestive heart failure, and coronary artery disease. The ECG criteria for premature junctional complex are the same as for PACs, except for the P wave and the PR interval. The P wave may be absent, may follow the QRS, or may occur before the QRS but with a PR interval of less than 0.12 seconds. Premature junctional complexes rarely produce significant symptoms. Treatment for frequent premature junctional complexes is the same as for frequent PACs. Junctional Rhythm. Junctional or idionodal rhythm occurs when the AV node, instead of the sinus node, becomes the pacemaker of the heart. When the sinus node slows (eg, from increased vagal tone) or when the impulse cannot be conducted through the AV node (eg, because of complete heart block), the AV node automatically discharges an impulse. The following are the ECG criteria for junctional rhythm not caused by complete heart block (Fig. 27-12): Ventricular and atrial rate: Ventricular rate 40 to 60; atrial rate also 40 to 60 if P waves are discernible Ventricular and atrial rhythm: Regular QRS shape and duration: Usually normal, but may be abnormal P wave: May be absent, after the QRS complex, or before the QRS; may be inverted, especially in lead II
Chapter 27
FIGURE 27-13
Management of Patients With Dysrhythmias and Conduction Problems
693
AV nodal reentry tachycardia in lead II.
PR interval: If P wave is in front of the QRS, PR interval is less than 0.12 second. P: QRS ratio: 1⬊1 or 0⬊1 Junctional rhythm may produce signs and symptoms of reduced cardiac output. If so, the treatment is the same as for sinus bradycardia. Emergency pacing may be needed. Atrioventricular Nodal Reentry Tachycardia. AV nodal reentry tachycardia occurs when an impulse is conducted to an area in the AV node that causes the impulse to be rerouted back into the same area over and over again at a very fast rate. Each time the impulse is conducted through this area, it is also conducted down into the ventricles, causing a fast ventricular rate. AV nodal reentry tachycardia that has an abrupt onset and an abrupt cessation with a QRS of normal duration had been called paroxysmal atrial tachycardia (PAT). Factors associated with the development of AV nodal reentry tachycardia include caffeine, nicotine, hypoxemia, and stress. Underlying pathologies include coronary artery disease and cardiomyopathy. The ECG criteria are as follows (Fig. 27-13): Ventricular and atrial rate: Atrial rate usually ranges between 150 to 250; ventricular rate usually ranges between 75 to 250 Ventricular and atrial rhythm: Regular; sudden onset and termination of the tachycardia QRS shape and duration: Usually normal, but may be abnormal P wave: Usually very difficult to discern PR interval: If P wave is in front of the QRS, PR interval is less than 0.12 seconds P: QRS ratio: 1⬊1, 2⬊1 The clinical symptoms vary with the rate and duration of the tachycardia and the patient’s underlying condition. The tachycardia usually is of short duration, resulting only in palpitations. A fast rate may also reduce cardiac output, resulting in significant signs and symptoms such as restlessness, chest pain, shortness of breath, pallor, hypotension, and loss of consciousness. Treatment is aimed at breaking the reentry of the impulse. Vagal maneuvers, such as carotid sinus massage (Fig. 27-14), gag reflex, breath holding, and immersing the face in ice water, increase parasympathetic stimulation, causing slower conduction through the AV node and blocking the reentry of the rerouted impulse. Some patients have learned to use some of these methods to terminate the episode on their own. Because of the risk of a cerebral embolic event, carotid sinus massage is
contraindicated in patients with carotid bruits. If the vagal maneuvers are ineffective, the patient may then receive a bolus of adenosine, verapamil, or diltiazem. Cardioversion is the treatment of choice if the patient is unstable or does not respond to the medications. If P waves cannot be identified, the rhythm may be called supraventricular tachycardia (SVT), which indicates only that it is not ventricular tachycardia (VT). SVT could be atrial fibrillation, atrial flutter, or AV nodal reentry tachycardia, among others. Vagal maneuvers and adenosine are used to slow conduction in the AV node to allow visualization of the P waves. VENTRICULAR DYSRHYTHMIAS Premature Ventricular Complex. Premature ventricular complex (PVC) is an impulse that starts in a ventricle and is conducted through the ventricles before the next normal sinus impulse. PVCs can occur in healthy people, especially with the use of caffeine, nicotine, or alcohol. They are also caused by cardiac ischemia or infarction, increased workload on the heart (eg, exercise, fever, hypervolemia, heart failure, tachycardia), digitalis toxicity, hypoxia, acidosis, or electrolyte imbalances, especially hypokalemia. In the absence of disease, PVCs are not serious. In the patient with an acute MI, PVCs may indicate the need for more aggressive therapy. PVCs may indicate the possibility of ensuing VT. However, PVCs that are (1) more frequent than 6 per minute,
FIGURE 27-14
Carotid sinus massage.
694
Unit 6
CARDIOVASCULAR, CIRCULATORY, AND HEMATOLOGIC FUNCTION
(2) multifocal or polymorphic (having different shapes), (3) occur two in a row (pair), and (4) occur on the T wave (the vulnerable period of ventricular depolarization) have not been found to be precursors of VT (Cardiac Arrhythmia Suppression Trial Investigators, 1989). These PVCs are no longer considered as warning or complex PVCs. In a rhythm called bigeminy, every other complex is a PVC. Trigeminy is a rhythm in which every third complex is a PVC, and quadrigeminy is a rhythm in which every fourth complex is a PVC. PVCs have the following characteristics on the ECG (Fig. 27-15): Ventricular and atrial rate: Depends on the underlying rhythm (eg, sinus rhythm) Ventricular and atrial rhythm: Irregular due to early QRS, creating one RR interval that is shorter than the others. PP interval may be regular, indicating that the PVC did not depolarize the sinus node. QRS shape and duration: Duration is 0.12 seconds or longer; shape is bizarre and abnormal P wave: Visibility of P wave depends on the timing of the PVC; may be absent (hidden in the QRS or T wave) or in front of the QRS. If the P wave follows the QRS, the shape of the P wave may be different. PR interval: If the P wave is in front of the QRS, the PR interval is less than 0.12 seconds. P: QRS ratio: 0⬊1; 1⬊1 The patient may feel nothing or may say that the heart “skipped a beat.” The effect of a PVC depends on its timing in the cardiac cycle and how much blood was in the ventricles when they contracted. Initial treatment is aimed at correcting the cause, if possible. Lidocaine (Xylocaine) is the medication most commonly used for immediate, short-term therapy (see Table 27-1). Long-term pharmacotherapy for only PVCs is not indicated. Ventricular Tachycardia. Ventricular tachycardia (VT) is defined as three or more PVCs in a row, occurring at a rate exceeding 100 beats per minute. The causes are similar to those for PVC. VT is usually associated with coronary artery disease and may precede ventricular fibrillation. VT is an emergency because the patient is usually (although not always) unresponsive and pulseless. VT has the following characteristics (Fig. 27-16): Ventricular and atrial rate: Ventricular rate is 100 to 200 beats per minute; atrial rate depends on the underlying rhythm (eg, sinus rhythm) Ventricular and atrial rhythm: Usually regular; atrial rhythm may also be regular. QRS shape and duration: Duration is 0.12 seconds or more; bizarre, abnormal shape
*
FIGURE 27-15
*
P wave: Very difficult to detect, so atrial rate and rhythm may be indeterminable PR interval: Very irregular, if P waves seen. P: QRS ratio: Difficult to determine, but if P waves are apparent, there are usually more QRS complexes than P waves. The patient’s tolerance or lack of tolerance for this rapid rhythm depends on the ventricular rate and underlying disease. If the patient is stable, continuing the assessment, especially obtaining a 12-lead ECG, may be the only action necessary. Cardioversion may be the treatment of choice, especially if the patient is unstable. Several factors determine the initial medication used for treatment, including the following: identifying the rhythm as monomorphic (having a consistent QRS shape and rate) or polymorphic (having varying QRS shapes and rates); determining the existence of a prolonged QT interval before the initiation of VT; and ascertaining the patient’s heart function (normal or decreased). VT in a patient who is unconscious and without a pulse is treated in the same manner as ventricular fibrillation: immediate defibrillation is the action of choice. Ventricular Fibrillation. Ventricular fibrillation is a rapid but disorganized ventricular rhythm that causes ineffective quivering of the ventricles. There is no atrial activity seen on the ECG. Causes of ventricular fibrillation are the same as for VT; it may also result from untreated or unsuccessfully treated VT. Other causes include electrical shock and Brugada syndrome, in which the patient (frequently of Asian descent) has a structurally normal heart, few or no risk factors for coronary artery disease, and a family history of sudden cardiac death. Ventricular fibrillation has the following characteristics (Fig. 27-17): Ventricular rate: Greater than 300 per minute Ventricular rhythm: Extremely irregular, without specific pattern QRS shape and duration: Irregular, undulating waves without recognizable QRS complexes This dysrhythmia is always characterized by the absence of an audible heartbeat, a palpable pulse, and respirations. Because there is no coordinated cardiac activity, cardiac arrest and death are imminent if ventricular fibrillation is not corrected. Treatment of choice is immediate defibrillation and activation of emergency services. The importance of defibrillation is evident in one of the recent changes in basic life support (American Heart Association, 2000): placing a call for emergency assistance and calling for a defibrillator takes precedence over initiating cardiopulmonary resuscitation in the adult victim. Also, application of an automatic external defibrillator (AED) is included in basic life support classes. After defibrillation, eradicating causes and administering vasoactive and antiarrhythmic medications alternating with defibril-
= PVC
*
Multifocal PVCs in quadrigeminy in lead V1. Note regular PP interval.
*
Chapter 27
FIGURE 27-16
Management of Patients With Dysrhythmias and Conduction Problems
Ventricular tachycardia in lead V1.
lation are treatments used to try to convert the rhythm to normal sinus rhythm. Idioventricular Rhythm. Idioventricular rhythm, also called ventricular escape rhythm, occurs when the impulse starts in the conduction system below the AV node. When the sinus node fails to create an impulse (eg, from increased vagal tone), or when the impulse is created but cannot be conducted through the AV node (eg, due to complete AV block), the Purkinje fibers automatically discharge an impulse. The following are the ECG criteria when idioventricular rhythm is not caused by AV block (Fig. 27-18): Ventricular rate: Ranges between 20 and 40; if the rate exceeds 40, the rhythm is known as accelerated idioventricular rhythm (AIVR). Ventricular rhythm: Regular QRS shape and duration: Bizarre, abnormal shape; duration is 0.12 seconds or more Idioventricular rhythm commonly causes the patient to lose consciousness and experience other signs and symptoms of reduced cardiac output. In such cases, the treatment is the same as for pulseless electrical activity if the patient is in cardiac arrest or for bradycardia if the patient is not in cardiac arrest. Interventions may include identifying the underlying cause, administering intravenous atropine and vasopressor medications, and initiating emergency transcutaneous pacing. In some cases, idioventricular rhythm may cause no symptoms of reduced cardiac output. However, bed rest is prescribed so as not to increase the cardiac workload. Ventricular Asystole. Commonly called flatline, ventricular asystole (Fig. 27-19) is characterized by absent QRS complexes, although P waves may be apparent for a short duration in two
FIGURE 27-17
695
Ventricular fibrillation in lead II.
different leads. There is no heartbeat, no palpable pulse, and no respiration. Without immediate treatment, ventricular asystole is fatal. Cardiopulmonary resuscitation and emergency services are necessary to keep the patient alive. The guidelines for advanced cardiac life support (American Heart Association, 2000) state that the key to successful treatment is rapid assessment to identify a possible cause, which may be hypoxia, acidosis, severe electrolyte imbalance, drug overdose, or hypothermia. Intubation and establishment of intravenous access are the first recommended actions. Transcutaneous pacing may be attempted. A bolus of intravenous epinephrine should be administered and repeated at 3- to 5-minute intervals, followed by 1-mg boluses of atropine at 3- to 5-minute intervals. Because of the poor prognosis associated with asystole, if the patient does not respond to these actions and others aimed at correcting underlying causes, resuscitation efforts are usually ended (“the code is called”) unless special circumstances (eg, hypothermia) exist. CONDUCTION ABNORMALITIES When assessing the rhythm strip, the nurse takes care first to identify the underlying rhythm (eg, sinus rhythm, sinus arrhythmia). Then the PR interval is assessed for the possibility of an AV block. AV blocks occur when the conduction of the impulse through the AV nodal area is decreased or stopped. These blocks can be caused by medications (eg, digitalis, calcium channel blockers, beta-blockers), myocardial ischemia and infarction, valvular disorders, or myocarditis. If the AV block is caused by increased vagal tone (eg, suctioning, pressure above the eyes or on large vessels, anal stimulation), it is commonly accompanied by sinus bradycardia. The clinical signs and symptoms of a heart block vary with the resulting ventricular rate and the severity of any underlying dis-
696
FIGURE 27-18
Unit 6
CARDIOVASCULAR, CIRCULATORY, AND HEMATOLOGIC FUNCTION
Idioventricular rhythm in lead V1.
ease processes. Whereas first-degree AV block rarely causes any hemodynamic effect, the other blocks may result in decreased heart rate, causing a decrease in perfusion to vital organs, such as the brain, heart, kidneys, lungs, and skin. A patient with third-degree AV block caused by digitalis toxicity may be stable; another patient with the same rhythm caused by acute MI may be unstable. Health care providers must always keep in mind the need to treat the patient, not the rhythm. The treatment is based on the hemodynamic effect of the rhythm.
not depolarized by the blocked atrial impulse, the AV node has time to fully repolarize, so that the next atrial impulse can be conducted within the shortest amount of time. Second-degree AV block, type I has the following characteristics (Fig. 27-21): Ventricular and atrial rate: Depends on the underlying rhythm Ventricular and atrial rhythm: The PP interval is regular if the patient has an underlying normal sinus rhythm; the RR interval characteristically reflects a pattern of change. Starting from the RR that is the longest, the RR interval gradually shortens until there is another long RR interval. QRS shape and duration: Usually normal, but may be abnormal P wave: In front of the QRS complex; shape depends on underlying rhythm PR interval: PR interval becomes longer with each succeeding ECG complex until there is a P wave not followed by a QRS. The changes in the PR interval are repeated between each “dropped” QRS, creating a pattern in the irregular PR interval measurements. P: QRS ratio: 3⬊2, 4⬊3, 5⬊4, and so forth
First-Degree Atrioventricular Block. First-degree heart block occurs when all the atrial impulses are conducted through the AV node into the ventricles at a rate slower than normal. This conduction disorder has the following characteristics (Fig. 27-20): Ventricular and atrial rate: Depends on the underlying rhythm Ventricular and atrial rhythm: Depends on the underlying rhythm QRS shape and duration: Usually normal, but may be abnormal P wave: In front of the QRS complex; shows sinus rhythm, regular shape PR interval: Greater than 0.20 seconds; PR interval measurement is constant. P: QRS ratio: 1⬊1 Second-Degree Atrioventricular Block, Type I. Second-degree, type I heart block occurs when all but one of the atrial impulses are conducted through the AV node into the ventricles. Each atrial impulse takes a longer time for conduction than the one before, until one impulse is fully blocked. Because the AV node is
FIGURE 27-19
Second-Degree Atrioventricular Block, Type II. Second-degree, type II heart block occurs when only some of the atrial impulses are conducted through the AV node into the ventricles. Seconddegree AV block, type II has the following characteristics (Fig. 27-22):
Asystole. (Always check two different leads to confirm rhythm.)
Ventricular and atrial rate: Depends on the underlying rhythm Ventricular and atrial rhythm: The PP interval is regular if the patient has an underlying normal sinus rhythm. The RR
Chapter 27
Management of Patients With Dysrhythmias and Conduction Problems
697
PR INTERVAL
FIGURE 27-20
Sinus rhythm with first-degree AV block in lead II.
Regular PP intervals
Irregular RR intervals
*
PR
PR
PR
*
PR
PR
PR
FIGURE 27-21 Sinus rhythm with second-degree AV block, type I in lead II. Note progressively longer PR durations until there is a nonconducted P wave, indicated by the asterisk (*).
Irregular RR intervals
Regular PP intervals
*
*
= nonconducted P-waves
* FIGURE 27-22
*
PR
PR
PR
*
PR
PR
Sinus rhythm with second-degree AV block, type II in lead V1; note constant PR interval.
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NURSING PROCESS: THE PATIENT WITH A DYSRHYTHMIA
interval is usually regular but may be irregular, depending on the P⬊QRS ratio. QRS shape and duration: Usually abnormal, but may be normal P wave: In front of the QRS complex; shape depends on underlying rhythm. PR interval: PR interval is constant for those P waves just before QRS complexes. P: QRS ratio: 2⬊1, 3⬊1, 4⬊1, 5⬊1, and so forth
Assessment Major areas of assessment include possible causes of the dysrhythmia and the dysrhythmia’s effect on the heart’s ability to pump an adequate blood volume. When cardiac output is reduced, the amount of oxygen reaching the tissues and vital organs is diminished. This diminished oxygenation produces the signs and symptoms associated with dysrhythmias. If these signs and symptoms are severe or if they occur frequently, the patient may experience significant distress and disruption of daily life. A health history is obtained to identify any previous occurrences of decreased cardiac output, such as syncope (fainting), lightheadedness, dizziness, fatigue, chest discomfort, and palpitations. Coexisting conditions that could be a possible cause of the dysrhythmia (eg, heart disease, chronic obstructive pulmonary disease) may also be identified. All medications, prescribed and over-the-counter (including herbs and nutritional supplements), are reviewed. Some medications (eg, digoxin) can cause dysrhythmias. A thorough psychosocial assessment is performed to identify the possible effects of the dysrhythmia and to determine whether anxiety is a significant contributing factor. The nurse conducts a physical assessment to confirm the data obtained from the history and to observe for signs of diminished cardiac output during the dysrhythmic event, especially changes in level of consciousness. The nurse directs attention to the skin, which may be pale and cool. Signs of fluid retention, such as neck vein distention and crackles and wheezes auscultated in the lungs, may be detected. The rate and rhythm of apical and peripheral pulses are also assessed, and any pulse deficit is noted. The nurse auscultates for extra heart sounds (especially S3 and S4) and for heart murmurs, measures blood pressure, and determines pulse pressures. A declining pulse pressure indicates reduced cardiac output. Just one assessment may not disclose significant changes in cardiac output; therefore, the nurse compares multiple assessment findings over time, especially those that occur with and without the dysrhythmia.
Third-Degree Atrioventricular Block. Third-degree heart block occurs when no atrial impulse is conducted through the AV node into the ventricles. In third-degree heart block, two impulses stimulate the heart: one stimulates the ventricles (eg, junctional or ventricular escape rhythm), represented by the QRS complex, and one stimulates the atria (eg, sinus rhythm, atrial fibrillation), represented by the P wave. P waves may be seen, but the atrial electrical activity is not conducted down into the ventricles to cause the QRS complex, the ventricular electrical activity. This is called AV dissociation. Complete block (third-degree AV block) has the following characteristics (Fig. 27-23): Ventricular and atrial rate: Depends on the escape and underlying atrial rhythm Ventricular and atrial rhythm: The PP interval is regular and the RR interval is regular; however, the PP interval is not equal to the RR interval. QRS shape and duration: Depends on the escape rhythm; in junctional escape, QRS shape and duration are usually normal, and in ventricular escape, QRS shape and duration are usually abnormal. P wave: Depends on underlying rhythm PR interval: Very irregular P: QRS ratio: More P waves than QRS complexes Based on the cause of the AV block and the stability of the patient, treatment is directed toward increasing the heart rate to maintain a normal cardiac output. If the patient is stable and has no symptoms, no treatment is indicated other than decreasing or eradicating the cause (eg, withholding the medication or treatment). If the patient is short of breath, complains of chest pain or lightheadedness, or has low blood pressure, an intravenous bolus of atropine is the initial treatment of choice. If the patient does not respond to atropine or has an acute MI, transcutaneous pacing should be started. A permanent pacemaker may be necessary if the block persists.
Diagnosis NURSING DIAGNOSES Based on assessment data, major nursing diagnoses of the patient may include:
Regular PP intervals
Regular RR intervals
*
PR
FIGURE 27-23 intervals.
*
PR
PR
* Sinus rhythm with third-degree AV block and idioventricular rhythm in lead V ; note irregular PR 1
= P-wave hidden in the t-wave
Chapter 27
Management of Patients With Dysrhythmias and Conduction Problems
• Decreased cardiac output • Anxiety related to fear of the unknown • Deficient knowledge about the dysrhythmia and its treatment
COLLABORATIVE PROBLEMS/ POTENTIAL COMPLICATIONS In addition to cardiac arrest, a potential complication that may develop over time is heart failure. Another potential complication, especially with atrial fibrillation, is a thromboembolic event. If the dysrhythmia necessitates treatment with medication, the beneficial and detrimental effects must be assessed.
Planning and Goals The major goals for the patient may include eradicating or decreasing the incidence of the dysrhythmia (by decreasing contributory factors) to maintain cardiac output, minimizing anxiety, and acquiring knowledge about the dysrhythmia and its treatment.
Nursing Interventions MONITORING AND MANAGING THE DYSRHYTHMIA The nurse regularly evaluates blood pressure, pulse rate and rhythm, rate and depth of respirations, and breath sounds to determine the dysrhythmia’s hemodynamic effect. The nurse also asks patients about episodes of lightheadedness, dizziness, or fainting as part of the ongoing assessment. If a patient with a dysrhythmia is hospitalized, the nurse may obtain a 12-lead ECG, continuously monitor the patient, and analyze rhythm strips to track the dysrhythmia. Control of the incidence or the effect of the dysrhythmia, or both, is often achieved by the use of antiarrhythmic medications. The nurse assesses and observes for the beneficial and adverse effects of each of the medications. The nurse also manages medication administration carefully so that a constant serum blood level of the medication is maintained at all times. In addition to medication, the nurse assesses for factors that contribute to the dysrhythmia (eg, caffeine, stress, nonadherence to the medication regimen) and assists the patient in developing a plan to make lifestyle changes that eliminate or reduce these factors. MINIMIZING ANXIETY When the patient experiences episodes of dysrhythmia, the nurse maintains a calm and reassuring attitude. This demeanor fosters a trusting relationship with the patient and assists in reducing anxiety (reducing the sympathetic response). Successes are emphasized with the patient to promote a sense of confidence in living with a dysrhythmia. For example, if a patient is experiencing episodes of dysrhythmia and a medication is administered that begins to reduce the incidence of the dysrhythmia, the nurse communicates that information to the patient. The nursing goal is to maximize the patient’s control and to make the unknown less threatening. PROMOTING HOME AND COMMUNITY-BASED CARE Teaching Patients Self-Care When teaching patients about dysrhythmias, the nurse presents the information in terms that are understandable and in a manner that is not frightening or threatening. The nurse explains the importance of maintaining therapeutic serum levels of anti-
699
arrhythmic medications so that the patient understands why medications should be taken regularly each day. In addition, the relationship between a dysrhythmia and cardiac output is explained so that the patient understands the rationale for the medical regimen. If the patient has a potentially lethal dysrhythmia, it is also important to establish with the patient and family a plan of action to take in case of an emergency. This allows the patient and family to feel in control and prepared for possible events. A referral for home care usually is not necessary for the patient with a dysrhythmia unless the patient is hemodynamically unstable and has significant symptoms of decreased cardiac output. Home care is also warranted if the patient has significant comorbidities, socioeconomic issues, or limited self-management skills that could potentiate the risk for nonadherence to the therapeutic regimen.
Evaluation EXPECTED PATIENT OUTCOMES Expected patient outcomes may include: 1. Maintains cardiac output a. Demonstrates heart rate, blood pressure, respiratory rate, and level of consciousness within normal ranges b. Demonstrates no or decreased episodes of dysrhythmia 2. Experiences reduced anxiety a. Expresses a positive attitude about living with the dysrhythmia b. Expresses confidence in ability to take appropriate actions in an emergency 3. Expresses understanding of the dysrhythmia and its treatment a. Explains the dysrhythmia and its effects b. Describes the medication regimen and its rationale c. Explains the need for therapeutic serum level of the medication d. Describes a plan to eradicate or limit factors that contribute to the occurrence of the dysrhythmia e. States actions to take in the event of an emergency
Adjunctive Modalities and Management Dysrhythmia treatments depend on whether the disorder is acute or chronic as well as on the cause of the dysrhythmia and its actual or potential hemodynamic effects. Acute dysrhythmias may be treated with medications or with external electrical therapy. Many antiarrhythmic medications are used to treat atrial and ventricular tachydysrhythmias. These medications are summarized in Table 27-1. The choice of medication depends on the specific dysrhythmia, presence of cardiac failure and other diseases, and the patient’s response to previous treatment. The nurse is responsible for monitoring and documenting the patient’s responses to the medication and for making sure that the patient has the knowledge and ability to manage the medication regimen. If medications alone are ineffective in eradicating or decreasing the dysrhythmia, certain adjunctive mechanical therapies are available. The most common are pacemakers for bradycardias and tachycardias, elective cardioversion and defibrillation for acute tachydysrhythmia, and implantable devices for chronic tachydysrhythmia. Surgical treatments, although less common, are also available.
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PACEMAKER THERAPY A pacemaker is an electronic device that provides electrical stimuli to the heart muscle. Pacemakers are usually used when a patient has a slower-than-normal impulse formation or a conduction disturbance that causes symptoms. They may also be used to control some tachydysrhythmias that do not respond to medication therapy. Biventricular (both ventricles) pacing may be used to treat advanced heart failure that does not respond to medication therapy. Pacemakers can be permanent or temporary. Permanent pacemakers are used most commonly for irreversible complete heart block. Temporary pacemakers are used (eg, after MI, after open heart surgery) to support patients until they improve or receive a permanent pacemaker.
Pacemaker lead enters external jugular vein Pacemaker lead tunnelled subcutaneously between pacemaker and external jugular vein Pacemaker placed beneath skin in pectoral region
Pacemaker Design and Types Pacemakers consist of two components: an electronic pulse generator and pacemaker electrodes, which are located on leads or wires. The generator contains the circuitry and batteries that generate the rate (measured in beats per minute) and the strength (measured in milliamperes [mA]) of the electrical stimulus delivered to the heart. The pacemaker electrodes convey the heart’s electrical activity through a lead to the generator; the generator’s electrical response to the information received is then transmitted to the heart. Leads can be threaded through a major vein into the right ventricle (endocardial leads), or they can be lightly sutured onto the outside of the heart and brought through the chest wall during open heart surgery (epicardial wires). The epicardial wires are always temporary and are removed by a gentle tug within a few days after surgery. The endocardial leads may be temporarily placed with catheters through the femoral, antecubital, brachial, or jugular vein (transvenous wires), usually guided by fluoroscopy. The endocardial and epicardial wires are connected to a temporary generator, which is about the size of a small paperback book. The energy source for a temporary generator is a common household battery; monitoring for pacemaker malfunctioning and battery failure is a nursing responsibility. This type of pacemaker therapy necessitates hospitalization of the patient. The endocardial leads also may be placed permanently, usually through the external jugular vein, and connected to a permanent generator, which is usually implanted underneath the skin in a subcutaneous pocket in the pectoral region or below the clavicle (Fig. 27-24). Sometimes an abdominal site is selected. This procedure is usually performed in a cardiac catheterization laboratory with the patient receiving a local anesthetic. Permanent pacemaker generators are insulated to protect against body moisture and warmth. There are several different energy sources for permanent generators: mercury-zinc batteries (which last 3 to 4 years), lithium cell units (up to 10 years), and nuclear-powered sources such as plutonium 238 (up to 20 years). Some of the batteries are rechargeable. If the battery is not rechargeable and failure is impending, the old generator is removed and the new one is connected to the existing leads and reimplanted in the already existing subcutaneous pocket. This procedure is usually performed with the patient receiving a local anesthetic. Hospitalization of the patient is needed for implantation or battery replacement. If a patient suddenly develops a bradycardia, emergency pacing may be started with transcutaneous pacing, which most defibrillators are now equipped to perform. AEDs are not able to do transcutaneous pacing (see later discussion). Large pacing ECG electrodes (sometimes the same conductive pads that are used for
Tip of lead (electrode) lodged in apex of right ventricle
FIGURE 27-24 Implanted transvenous pacing lead (with electrode) and pacemaker generator. cardioversion and defibrillation) are placed on the patient’s chest and back. The electrodes are connected to the defibrillator, which is the temporary pacemaker generator (Fig. 27-25). Because the impulse must travel through the patient’s skin and tissue before reaching the heart, transcutaneous pacing can cause significant discomfort and is intended to be used only in emergencies. This type of pacing necessitates hospitalization. If the patient is alert, the use of sedation and analgesia should be discussed with the physician.
Pacemaker Generator Functions Because of the sophistication and wide use of pacemakers, a universal code has been adopted to provide a means of safe communication about their function. The coding is referred to as the NASPE-BPEG code because it is sanctioned by the North American Society of Pacing and Electrophysiology and the British Pacing and Electrophysiology Group. The complete code consists of five letters, but only the first three are commonly used. The first letter of the code identifies the chamber or chambers being paced—that is, the chamber containing a pacing electrode. The letter characters for this code are A (atrium), V (ventricle), or D (dual, meaning both A and V). The second letter describes the chamber or chambers being sensed by the pacemaker generator. Information from the electrode within the chamber is sent to the generator for interpretation and action by the generator. The possible letter characters are A (atrium), V (ventricle), D (dual), and O (indicating that the sensing function is turned off). The third letter of the code describes the type of response by the pacemaker to what is sensed. The possible letter characters used to describe this response are I (inhibited), T (triggered), D (dual, inhibited and triggered), and O (none). Inhibited response means that the response of the pacemaker is controlled by the activity of the patient’s heart; that is, the pacemaker will not func-
Chapter 27
Management of Patients With Dysrhythmias and Conduction Problems
701
FIGURE 27-25
Transcutaneous pacemaker with electrode pads connected to the anterior and posterior chest walls.
tion when the patient’s heart beats but will pace if no beat is sensed. In contrast, triggered response means that the pacemaker will provide a response (pace the heart) when it senses intrinsic heart activity. The fourth and fifth letters are used only with permanent pacemaker generators. The fourth letter of the code is related to a permanent generator’s ability to be programmed or reset. The possible letters are O (none), P (simple programmability), M (multiprogrammability; ability to change at least three factors, such as the rate at which pacing is initiated, the rate of pacing, and the amount of energy delivered), C (communicative or telemetry ability; information about the generator may be obtained [read or interrogated] with a hand-held device placed above the chest), and R (rate responsive capabilities; the ability of the pacemaker to change the rate from moment to moment based on parameters such as physical activity, acid-base changes, temperature, rate and depth of respirations, and oxygen saturation). A pacemaker with rate responsive ability will be capable of improving cardiac output during times of increased cardiac demand, such as with exercise. The fifth letter of the code indicates that the permanent generator has antitachycardia and/or defibrillation capability. The possible letters are P (antitachycardia pacing), S (shock; defibrillation), D (dual—antitachycardia pacing and shock), and O (none). Antitachycardia pacing is used to terminate tachycardias caused by a conduction disturbance called reentry, which is repetitive restimulation of the heart by the same impulse. An impulse or series of impulses is delivered to the heart by the pacemaker at a fast rate to collide with and stop the heart’s reentry conduction impulses, and therefore to stop the tachycardia. An example of a NASPE-BPEG code is DVI: D: Both the atrium and the ventricle have a pacing electrode in place. V: The pacemaker is sensing the activity of the ventricle only. I: The pacemaker’s stimulating effect is inhibited by ventricular activity—in other words, it does not create an impulse when the patient’s ventricle is active. The pacemaker paces the atrium and then the ventricle when no ventricular activity is sensed for a period of time (the time is individually programmed into the pacemaker for each patient). The type of generator and its selected settings depend on the patient’s dysrhythmia, underlying cardiac function, and age. A straight vertical line usually can be seen on the ECG when pacing is initiated. The line that represents pacing is called a pace-
maker spike. The appropriate ECG complex should immediately follow the pacing spike; therefore, a P wave should follow an atrial pacing spike and a QRS complex should follow a ventricular pacing spike. Because the impulse starts in a different place than the patient’s normal rhythm, the QRS complex or P wave that responds to pacing looks different from the patient’s normal ECG complex. Capture is a term used to denote that the appropriate complex followed the pacing spike. Pacemakers are generally set to sense and respond to intrinsic activity, which is called on-demand pacing (Fig. 27-26). If the pacemaker is set to pace but not to sense, it is called a fixed or asynchronous pacemaker (Fig. 27-27); this is written in code as AOO or VOO. The pacemaker will pace at a constant rate, independent of the patient’s intrinsic rhythm. Because AOO pacing stimulates only the atrium, it may be used in a patient who has undergone open heart surgery and develops sinus bradycardia. AOO pacing ensures synchrony between atrial stimulation and ventricular stimulation (and therefore contraction), as long as the patient has no conduction disturbances in the AV node. VOO is rare because of the risk that the pacemaker may deliver an impulse during the vulnerable repolarization phase, leading to VT.
Complications of Pacemaker Use Complications associated with pacemakers relate to their presence within the body, and improper functioning. The following complications may arise from a pacemaker:
• Local infection at the entry site of the leads for temporary • • • • • •
pacing, or at the subcutaneous site for permanent generator placement Bleeding and hematoma at the lead entry sites for temporary pacing, or at the subcutaneous site for permanent generator placement Hemothorax from puncture of the subclavian vein or internal mammary artery Ventricular ectopy and tachycardia from irritation of the ventricular wall by the endocardial electrode Movement or dislocation of the lead placed transvenously (perforation of the myocardium) Phrenic nerve, diaphragmatic (hiccuping may be a sign of this), or skeletal muscle stimulation if the lead is dislocated or if the delivered energy (mA) is set high Rarely, cardiac tamponade from bleeding resulting from removal of epicardial wires used for temporary pacing
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CARDIOVASCULAR, CIRCULATORY, AND HEMATOLOGIC FUNCTION F
*
*
FIGURE 27-26 Pacing with appropriate sensing (on-demand pacing) in lead V1. Arrows denote pacing spike. Asterisk (*) denotes intrinsic (patient’s own) beats, therefore no pacing. F denotes a fusion beat, which is a combination of an intrinsic beat and a paced beat occurring at the same time. In the initial hours after a temporary or permanent pacemaker is inserted, the most common complication is dislodgment of the pacing electrode. Minimizing patient activity can help to prevent this complication. If a temporary electrode is in place, the extremity through which the catheter has been advanced is immobilized. With a permanent pacemaker, the patient is instructed initially to restrict activity on the side of the implantation. The ECG is monitored very carefully to detect pacemaker malfunction. Improper pacemaker function, which can arise from failure in one or more components of the pacing system, is outlined in Table 27-2. The following data should be noted on the patient’s record: model of pacemaker, type of generator, date and time of insertion, location of pulse generator, stimulation threshold, pacer settings (eg, rate, energy output [mA], and duration between atrial and ventricular impulses [AV delay]). This information is important for identifying normal pacemaker function and diagnosing pacemaker malfunction. A patient experiencing pacemaker malfunction may develop signs and symptoms of decreased cardiac output. The degree to which these symptoms become apparent depends on the severity of the malfunction, the patient’s level of dependency on the pacemaker, and the patient’s underlying condition. Pacemaker malfunction is diagnosed by analyzing the ECG. Manipulating the electrodes, changing the generator’s settings, or replacing the pacemaker generator or leads (or both) may be necessary. Inhibition of permanent pacemakers can occur with exposure to strong electromagnetic fields (electromagnetic interference). However, recent pacemaker technology allows patients to safely use
FIGURE 27-27
most household electronic appliances and devices (eg, microwave ovens, electric tools) as long as they are not held close to the pacemaker generator. Gas-powered engines should be turned off before working on them. Objects that contain magnets (eg, the earpiece of a standard phone; large stereo speakers; magnet therapy products such as mattresses, jewelry, and wraps) should not be near the generator for longer than a few seconds. Patients are advised to use digital cellular phones on the side opposite the pacemaker generator. Large electromagnetic fields, such as those produced by magnetic resonance imaging (MRI), radio and TV transmitter towers and lines, transmission power lines (these are different from the distribution lines that bring electricity into a home), and electrical substations may cause electromagnetic interference. Patients should be cautioned to avoid such situations or to simply move farther away from the area if they experience dizziness or a feeling of rapid or irregular heartbeats (palpitations). Welding and use of a chain saw should be avoided. If such tools are used, precautionary steps such as limiting the welding current to a 60- to 130-ampere range or using electric rather than gasoline-powered chain saws are advised. The metal of the pacemaker generator may trigger some store and airport security alarms, but these alarm systems will not interfere with the pacemaker function. However, the handheld screening devices used in airports may interfere with the pacemaker. Patients should be advised to request a hand search instead of the handheld screening device. Patients also should be instructed to wear or carry medical identification to alert personnel to the presence of the pacemaker.
Fixed pacing or total loss of sensing pacing in lead V1; arrows denote pacing spikes.
Chapter 27
Table 27-2
Management of Patients With Dysrhythmias and Conduction Problems
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• Assessing Pacemaker Malfunction
PROBLEM
POSSIBLE CAUSE
INTERVENTION
Loss of capture—complex does not follow pacing spike
Inadequate stimulus Catheter malposition Battery depletion Electronic insulation break
Undersensing—pacing spike occurs at preset interval despite patient’s intrinsic rhythm
Sensitivity too high Electrical interference (eg, by a magnet) Faulty generator Sensitivity too low Electrical interference Battery depletion Battery depletion Loose or disconnected wires Perforation
Check security of all connections; increase milliamperage. Reposition extremity; turn patient to left side. Change battery. Change generator. Decrease sensitivity. Eliminate interference. Replace generator. Increase sensitivity. Eliminate interference. Change battery. Change battery. Check security of all connections. Obtain 12-lead ECG and portable chest x-ray. Assess for murmur. Call physician. Obtain 12-lead ECG and portable chest x-ray. Assess for murmur. Call physician. Decrease milliamperage. Turn pacer off. Call physician at once. Monitor closely for decreased cardiac output.
Oversensing—loss of pacing artifact; pacing does not occur at preset interval despite lack of intrinsic rhythm Loss of pacing—Total absence of pacing spikes
Change in pacing QRS shape
Septal perforation
Rhythmic diaphragmatic or chest wall twitching or hiccuping
Output too high Myocardial wall perforation
Pacemaker Surveillance Pacemaker clinics have been established to monitor patients and to test pulse generators for impending pacemaker battery failure. Several other factors, such as lead fracture, muscle inhibition, and insulation disruption, are assessed depending on the type of pacemaker and the equipment available. If indicated, the pacemaker is turned off for a few seconds, using a magnet or a programmer, while the ECG is recorded to assess the patient’s underlying cardiac rhythm. Another follow-up method is transtelephonic transmission of the generator’s pulse rate. Special equipment is used to transmit information about the patient’s pacemaker over the telephone to a receiving system at a pacemaker clinic. The information is converted into tones, which equipment at the clinic converts to an electronic signal and records on an ECG strip. The pacemaker rate and other data concerning pacemaker function are obtained and evaluated by a cardiologist. This simplifies the diagnosis of a failing generator, reassures the patient, and improves management when the patient is physically remote from pacemaker testing facilities.
NURSING PROCESS: THE PATIENT WITH A PACEMAKER Assessment After a temporary or a permanent pacemaker is inserted, the patient’s heart rate and rhythm are monitored by ECG. The pacemaker’s settings are noted and compared with the ECG recordings to assess pacemaker function. Pacemaker malfunction is detected by examining the pacemaker spike and its relationship to the surrounding ECG complexes (Fig. 27-28). In addition, cardiac output and hemodynamic stability are assessed to identify the patient’s response to pacing and the adequacy of pacing. The ap-
pearance or increasing frequency of dysrhythmia is observed and reported to the physician. The incision site where the pulse generator was implanted (or the entry site for the pacing electrode, if the pacemaker is a temporary transvenous pacemaker) is observed for bleeding, hematoma formation, or infection, which may be evidenced by swelling, unusual tenderness, unusual drainage, and increased heat. The patient may complain of continuous throbbing or pain. These symptoms are reported to the physician. The patient with a temporary pacemaker is also assessed for electrical interference and the development of microshock. The nurse observes for potential sources of electrical hazards. All electrical equipment used in the vicinity of the patient should be grounded. Improperly grounded equipment can generate leakage of current capable of producing ventricular fibrillation. Exposed wires must be carefully covered with nonconductive material to prevent accidental ventricular fibrillation from stray currents. The nurse, working with a biomedical engineer or electrician, should make certain that the patient is in an electrically safe environment. Patients, especially those receiving a permanent pacemaker, should be assessed for anxiety. In addition, for those receiving permanent pacemakers, the level of knowledge and learning needs of the patient and the family and the history of adherence to the therapeutic regimen should be identified.
Diagnosis NURSING DIAGNOSES Based on assessment data, major nursing diagnoses of the patient may include the following:
• Risk for infection related to pacemaker lead or generator insertion
• Risk for ineffective coping • Deficient knowledge regarding self-care program
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P
CARDIOVASCULAR, CIRCULATORY, AND HEMATOLOGIC FUNCTION
P
P
*
*
P
*
*
*
A F I
P
I
I
I
F
I
I
I
P
P
B
FIGURE 27-28
(A) Ventricular pacing with intermittent loss of capture (a pacing spike not followed by a QRS complex). (B) Ventricular pacing with loss of sensing (a pacing spike occurring at an inappropriate time). Key: ↑ = pacing spike; * = loss of capture; P = pacemaker-induced QRS complex; I = patient’s intrinsic QRS complex; F = fusion (a QRS complex formed by a merging of the patient’s intrinsic QRS complex and the pacemaker-induced QRS complex). Both in lead V1.
COLLABORATIVE PROBLEMS/ POTENTIAL COMPLICATIONS Based on the assessment findings, potential complications that may develop include decreased cardiac output related to pacemaker malfunction.
Planning and Goals The major goals for the patient may include absence of infection, adherence to a self-care program, effective coping, and maintenance of pacemaker function.
ceived changes (eg, loss of ability to participate in contact sports), the emotional response to the change (eg, anger), and how the patient responded to that emotion (eg, quickly became angry when talking with spouse). The nurse reassures the patient that the responses are normal, then assists the patient to identify realistic goals (eg, develop interest in another activity) and to develop a plan to attain those goals. The nurse may also teach the patient easy-to-use stress reduction techniques (eg, deep-breathing exercises) to facilitate coping. Education (Chart 27-3) may assist a patient to cope with changes that occur with pacemaker treatment. PROMOTING HOME AND COMMUNITY-BASED CARE
Nursing Interventions PREVENTING INFECTION The nurse changes the dressing regularly and inspects the insertion site for redness, swelling, soreness, or any unusual drainage. An increase in temperature should be reported to the physician. Changes in wound appearance are also reported to the physician. PROMOTING EFFECTIVE COPING The patient treated with a pacemaker experiences not only lifestyle and physical changes but also emotional changes. At different times during the healing process, the patient may feel angry, depressed, fearful, anxious, or a combination of these emotions. Although each patient uses individual coping strategies (eg, humor, prayer, communication with a significant other) to manage emotional distress, some strategies may work better than others. Signs that may indicate ineffective coping include social isolation, increased or prolonged irritability or depression, and difficulty in relationships. To promote effective coping strategies, the nurse must recognize the patient’s emotional state and assist the patient to explore his or her feelings. The nurse may help the patient to identify per-
Teaching Patients Self-Care After pacemaker insertion, the patient’s hospital stay may be less than 1 day, and follow-up in an outpatient clinic or office is common. The patient’s anxiety and feelings of vulnerability may interfere with the ability to learn information provided. Nurses often need to include home caregivers in the teaching and provide printed materials for use by the patient and caregiver. Priorities for learning are established with the patient and caregiver. Teaching may include the importance of periodic pacemaker monitoring, promoting safety, avoiding infection, and sources of electromagnetic interference (see Chart 27-3).
Evaluation EXPECTED PATIENT OUTCOMES Expected patient outcomes may include: 1. Remains free of infection a. Has normal temperature b. Has white blood cell count within normal range (5,000 to 10,000/mm3)
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Management of Patients With Dysrhythmias and Conduction Problems
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Chart 27-3 Home Care Checklist • The Patient With a Pacemaker At the completion of the home care instruction, the patient or caregiver will be able to: Monitor pacemaker function. • Describe the importance of reporting to physician or pacemaker clinic periodically as prescribed, so that the pacemaker’s rate and function can be monitored. This is especially important during the first month after implantation. • Adhere to monitoring schedule as instructed after implantation. • Check pulse daily. Report immediately any sudden slowing or increasing of the pulse rate. This may indicate pacemaker malfunction. • Resume more frequent monitoring when battery depletion is anticipated. (The time for reimplantation depends on the type of battery in use.) Promote safety and avoid infection. • Wear loose-fitting clothing around the area of the pacemaker. • State the reason for the slight bulge over the pacemaker implant. • Notify physician if the pacemaker area becomes red or painful. • Avoid trauma to the area of the pacemaker generator. • Study the manufacturer’s instructions and become familiar with the pacemaker. • Recognize that physical activity does not usually have to be curtailed, with the exception of contact sports. • Carry medical identification indicating physician’s name, type and model number of pacemaker, manufacturer’s name, pacemaker rate, and hospital where pacemaker was inserted. Electromagnetic interference: Describe the importance of the following: • Avoid large magnetic fields such as those surrounding magnetic resonance imaging, large motors, arc welding, electrical substations. Magnetic fields can deactivate the pacemaker. • Some electrical and small motor devices, as well as cellular phones, may interfere with pacemaker function if placed very close to the generator. Avoid leaning directly over devices, or ensure that contact is brief; place cellular phone on opposite side of generator. • Household items, such as microwave ovens, should not cause any concern. • When going through security gates (eg, at airports, government buildings) show identification card and request hand search. • Hospitalization may be necessary periodically to change battery or replace pacemaker unit.
c. Exhibits no redness or swelling of pacemaker insertion site 2. Adheres to a self-care program a. Responds appropriately when queried about the signs and symptoms of infection b. Identifies when to seek medical attention (as demonstrated in responses to signs and symptoms) c. Adheres to monitoring schedule d. Describes appropriate methods to avoid electromagnetic interference 3. Maintains pacemaker function (see Chart 27-3) a. Measures and records pulse rate at regular intervals b. Experiences no abrupt changes in pulse rate or rhythm
Patient
Caregiver
✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓
✓ ✓ ✓
✓
✓ ✓ ✓
✓ ✓
✓ ✓
✓ ✓
one paddle may be placed on the front of the chest and the other connected to an adapter with a long handle and placed under the patient’s back, which is called an anteroposterior placement (Fig. 27-30).
!
NURSING ALERT When using paddles, apply the appropriate conductant between the paddles and the patient’s skin. Do not substitute any other type of conductant, such as ultrasound gel.
CARDIOVERSION AND DEFIBRILLATION Cardioversion and defibrillation are treatments for tachydysrhythmias. They are used to deliver an electrical current to depolarize a critical mass of myocardial cells. When the cells repolarize, the sinus node is usually able to recapture its role as the heart’s pacemaker. One major difference between cardioversion and defibrillation has to do with the timing of the delivery of electrical current. Another major difference concerns the circumstance: defibrillation is usually performed as an emergency treatment, whereas cardioversion is usually, but not always, a planned procedure. Electrical current may be delivered through paddles or conductor pads. Both paddles may be placed on the front of the chest (Fig. 27-29), which is the standard paddle placement, or
✓
FIGURE 27-29
Standard paddle placement for defibrillation.
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CARDIOVASCULAR, CIRCULATORY, AND HEMATOLOGIC FUNCTION
Posterior
Anterior
• L
R
L
R
• •
FIGURE 27-30
Anteroposterior paddle placement for defibrillation.
• Instead of paddles, defibrillator multifunction conductor pads may be used (Fig. 27-31). The pads, which contain a conductive medium, are placed in the same position as the paddles. They are connected to the defibrillator and allow for hands-off defibrillation. This method reduces the risks of touching the patient during the procedure and increases electrical safety. AEDs use this type of delivery for the electrical current. Whether using pads or paddles, the nurse must observe two safety measures. First, maintain good contact between the pads or paddles (with a conductive medium) and the patient’s skin to prevent electrical current from leaking into the air (arcing) when the defibrillator is discharged. Second, ensure that no one is in contact with the patient or with anything that is touching the patient when the defibrillator is discharged, to minimize the chance that electrical current will be conducted to anyone other than the patient. When performing defibrillation or cardioversion, the nurse should remember these key points:
• Use multifunction conductor pads or paddles with a con• •
ducting agent between the paddles and the skin (the conducting agent is available as a sheet, gel, or paste). Place paddles or pads so that they do not touch the patient’s clothing or bed linen and are not near medication patches or direct oxygen flow. If cardioverting, ensure that the monitor leads are attached to the patient and that the defibrillator is in sync mode. If
L
R
•
defibrillating, ensure that the defibrillator is not in sync mode (most machines default to the “not-sync” mode). Do not charge the device until ready to shock; then keep thumbs and fingers off the discharge buttons until paddles or pads are on the chest and ready to deliver the electrical charge. Exert 20 to 25 pounds of pressure on the paddles to ensure good skin contact. Before pressing the discharge button, call “Clear!” three times: As “Clear” is called the first time, ensure that you are not touching the patient, bed or equipment; as “Clear” is called the second time, ensure that no one is touching the bed, the patient, or equipment, including the endotracheal tube or adjuncts; and as “Clear” is called the third time, perform a final visual check to ensure you and everyone else are clear of the patient and anything touching the patient. Record the delivered energy and the results (cardiac rhythm, pulse). After the event is complete, inspect the skin under the pads or paddles for burns; if any are detected, consult with the physician or a wound care nurse about treatment.
Cardioversion Cardioversion involves the delivery of a “timed” electrical current to terminate a tachydysrhythmia. In cardioversion, the defibrillator is set to synchronize with the ECG on a cardiac monitor so that the electrical impulse discharges during ventricular depolarization (QRS complex). Because there may be a short delay until recognition of the QRS, the discharge buttons must be held down until the shock has been delivered. The synchronization prevents the discharge from occurring during the vulnerable period of repolarization (T wave), which could result in VT or ventricular fibrillation. When the synchronizer is on, no electrical current will be delivered if the defibrillator does not discern a QRS complex. Sometimes the lead and the electrodes must be changed for the monitor to recognize the patient’s QRS complex. If the cardioversion is elective, anticoagulation for a few weeks before cardioversion may be indicated. Digoxin is usually withheld for 48 hours before cardioversion to ensure the resumption of sinus rhythm with normal conduction. The patient is instructed not to eat or drink for at least 8 hours before the procedure. Gel-covered paddles or conductor pads are positioned front and back (anteroposteriorly) for cardioversion. Before cardio-
R
L
FIGURE 27-31 Back
Front
rillation.
Multifunction pads for defib-
Chapter 27
Management of Patients With Dysrhythmias and Conduction Problems
version, the patient receives intravenous sedation as well as an analgesic medication or anesthesia. Respiration is then supported with supplemental oxygen delivered by a bag-mask-valve device with suction equipment readily available. Although patients rarely require intubation, equipment is nearby if it is needed. The amount of voltage used varies from 25 to 360 joules, depending on the defibrillator’s technology and the type of dysrhythmia. If ventricular fibrillation occurs after cardioversion, the defibrillator is used to defibrillate the patient (sync mode is not used). Indications of a successful response are conversion to sinus rhythm, adequate peripheral pulses, and adequate blood pressure. Because of the sedation, airway patency must be maintained and the patient’s state of consciousness assessed. Vital signs and oxygen saturation are monitored and recorded until the patient is stable and recovered from sedation and the effects of analgesic medications or anesthesia. ECG monitoring is required during and after cardioversion.
Defibrillation Defibrillation is used in emergency situations as the treatment of choice for ventricular fibrillation and pulseless VT. Defibrillation depolarizes a critical mass of myocardial cells at once; when they repolarize, the sinus node usually recaptures its role as the pacemaker. The electrical voltage required to defibrillate the heart is usually greater than that required for cardioversion. If three defibrillations of increasing voltage have been unsuccessful, cardiopulmonary resuscitation is initiated and advanced life support treatments are begun. The use of epinephrine or vasopressin may make it easier to convert the dysrhythmia to a normal rhythm with defibrillation. These drugs may also increase cerebral and coronary artery blood flow. After the medication is administered and 1 minute of cardiopulmonary resuscitation is performed, defibrillation is again administered. Antiarrhythmic medications such as amiodarone (Cordarone, Pacerone), lidocaine (Xylocaine), magnesium, or procainamide (Pronestyl) are given if ventricular dysrhythmia persists (see Table 27-1). This treatment continues until a stable rhythm resumes or until it is determined that the patient cannot be revived. IMPLANTABLE CARDIOVERTER DEFIBRILLATOR The implantable cardioverter defibrillator (ICD) is a device that detects and terminates life-threatening episodes of VT or ventricular fibrillation in high-risk patients. Patients at high risk are those who have survived sudden cardiac death syndrome, usually caused by ventricular fibrillation, or have experienced symptomatic VT (syncope secondary to VT). In addition, an ICD may be indicated for patients who have survived an MI but are at high risk for cardiac arrest. An ICD consists of a generator and at least one lead that can sense intrinsic electrical activity and deliver an electrical impulse. The device is usually implanted much like a pacemaker (Fig. 27-32). ICDs are designed to respond to two criteria: a rate that exceeds a predetermined level, and a change in the isoelectric line segments. When a dysrhythmia occurs, rate sensors take 5 to 10 seconds to sense the dysrhythmia. Then the device takes several seconds to charge and deliver the programmed charge through the lead to the heart. Battery life is about 5 years but varies depending on use of the ICD over time. The battery is checked during follow-up visits. Antiarrhythmic medication usually is administered with this technology to minimize the occurrence of the tachydysrhythmia and to reduce the frequency of ICD discharge.
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The first defibrillator, which was implanted in 1980 at Johns Hopkins University, simply defibrillated the heart. Today, however, several devices are available, and many are programmed for multiple treatments (Atlee & Bernstein, 2001). Each device offers a different delivery sequence, but all are capable of delivering high-energy (high-intensity) defibrillation to treat a tachycardia (atrial or ventricular). The device may deliver up to six shocks if necessary. Some ICDs can respond with antitachycardia pacing, in which the device delivers electrical impulses at a fast rate in an attempt to disrupt the tachycardia, by low-energy (low-intensity) cardioversion, by defibrillation, or all three (Atlee & Bernstein, 2001). Some also have pacemaker capability if the patient develops bradycardia, which sometimes occurs after treatment of the tachycardia. Usually the mode is VVI (V, paces the ventricle; V, senses ventricular activity; I, paces only if the ventricles do not depolarize) (Atlee & Bernstein, 2001). Some ICDs also deliver lowenergy cardioversion, and some also treat atrial fibrillation (Bubien & Sanchez, 2001; Daoud et al., 2000). Which device is used and how it is programmed depends on the patient’s dysrhythmia. Complications are similar to those associated with pacemaker insertion. The primary complication associated with the ICD is surgery-related infection. There are a few complications associated with the technical aspects of the equipment, such as premature battery depletion and dislodged or fractured leads. Despite the possible complications, the consensus among clinicians is that the benefits of ICD therapy exceed the risks. Nursing interventions for the patient with an ICD are provided throughout the preoperative, perioperative, and postoperative phases. In addition to providing the patient and family with explanations regarding implantation of the ICD in the preoperative phase, the nurse may need to manage acute episodes of lifethreatening dysrhythmias. In the perioperative and postoperative phases, the nurse carefully observes the patient’s responses to the ICD and provides the patient and family with further teaching as needed (White, 2000) (Chart 27-4). The nurse can also assist the patient and family in making lifestyle changes necessitated by the dysrhythmia and resulting ICD implantation (Dougherty, Benoliel, & Bellin, 2000).
FIGURE 27-32 The implantable cardioverter defibrillator (ICD) consists of a generator and a sensing/pacing/defibrillating electrode.
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Unit 6
CARDIOVASCULAR, CIRCULATORY, AND HEMATOLOGIC FUNCTION
Chart 27-4 Home Care Checklist • The Patient With an ICD At the completion of the home care instruction, the patient or caregiver will be able to: Avoid infection at the ICD insertion site. • Observe incision site daily for redness, swelling, and heat. • Take temperature; report any increase. • Avoid tight restrictive clothing that may cause friction over the insertion site. Adhere to activity restrictions. • Movement of arm may continue to be restricted until incision heals if the ICD was implanted in pectoral region. • Avoid heavy lifting. • Discuss safety of activities (eg, driving) with physician. • Avoid contact sports. Electromagnetic interference: Understand the importance of the following: • Avoid large magnetic fields such as those created by magnetic resonance imaging, large motors, arc welding, electrical substations, and so forth. Magnetic fields may deactivate the ICD, negating any effect on a dysrhythmia. • At security gates at airports, government buildings, or other secured areas, show identification card and request a hand search. • Some electrical and small motor devices, as well as cellular phones, may interfere with the functioning of the ICD if placed very close to the ICD. Avoid leaning directly over devices, or ensure contact is of brief duration; place cellular phone on opposite side of ICD. • Household appliances (eg, microwave ovens) should not cause any concern. Promote safety. • Describe what to do if symptoms occur and notify physician if any discharges seem unusual. • Maintain a log that records discharges. Record events that precipitate the sensation of shock. This provides important data for the physician to use in readjusting the medical regimen. • Encourage family members to attend a CPR class. • Call 911 for emergency assistance if feeling of dizziness occurs. • Wear medical identification (eg, Medic-Alert) that includes physician information. • Avoid frightening family or friends with unexpected shocks, which will not harm them. Inform family and friends that in the event they are in contact with the patient when a shock is delivered, they may also feel the shock. It is especially important to warn sexual partners that this may occur. • Discuss psychological responses to the ICD implantation, such as changes in self-image, depression due to loss of mobility secondary to driving restrictions, fear of shocks, increased anxiety, concerns that sexual activity may trigger the ICD, and changes in partner relationship. Follow-up care • Adhere to appointments that are scheduled to test electronic performance of ICD. Remember to take log of discharges to review with physician. • Attend an ICD support group within the area.
ELECTROPHYSIOLOGIC STUDIES An electrophysiology (EP) study is used to evaluate and treat various dysrhythmias that have caused cardiac arrest or significant symptoms. It also is indicated for patients with symptoms that suggest a dysrhythmia that has gone undetected and undiagnosed by other methods. An EP study is used to • Identify the impulse formation and propagation through the cardiac electrical conduction system • Assess the function or dysfunction of the SA and AV nodal areas • Identify the location (called mapping) and mechanism dysrhythmogenic foci • Assess the effectiveness of antiarrhythmic medications and devices for the patient with a dysrhythmia • Treat certain dysrhythmias through the destruction of the causative cells (ablation)
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✓
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An EP procedure is a type of cardiac catheterization that is performed in a specially equipped cardiac catheterization laboratory. The patient is awake but lightly sedated. Usually a catheter with multiple electrodes is inserted through the femoral vein, threaded through the inferior vena cava, and advanced into the heart. The electrodes are positioned within the heart at specific locations—for instance, in the right atrium near the sinus node, in the coronary sinus, near the tricuspid valve, and at the apex of the right ventricle. The number and placement of electrodes depend on the type of study being conducted. These electrodes allow the electrical signal to be recorded from within the heart (intracardiogram). The electrodes also allow the clinician to introduce a pacing stimulus to the intracardiac area at a precisely timed interval and rate, thereby stimulating the area (programmed stimulation). An area of the heart may be paced at a rate much faster than the normal rate of automaticity, the rate at which impulses are spon-
Chapter 27
Management of Patients With Dysrhythmias and Conduction Problems
taneously formed (eg, in the sinus node). This allows the pacemaker to become an artificial focus of automaticity and to assume control (overdrive suppression). Then the pacemaker is stopped suddenly, and the time it takes for the sinus node to resume control is assessed. A prolonged time indicates dysfunction of the sinus node. One of the main purposes of programmed stimulation is to assess the ability of the area surrounding the electrode to cause a reentry dysrhythmia. One or a series of premature impulses is delivered to an area in an attempt to cause the tachydysrhythmia. Because the precise location of the suspected area and the specific timing of the pacing needed are unknown, the electrophysiologist uses several different techniques to cause the dysrhythmia during the study. If the dysrhythmia can be reproduced by programmed stimulation, it is called inducible. Once a dysrhythmia is induced, a treatment plan is determined and implemented. If, on the follow-up EP study, the tachydysrhythmia cannot be induced, then the treatment is determined to be effective. Different medications may be administered and combined with electrical devices (pacemaker, ICD) to determine the most effective treatment to suppress the dysrhythmia. Complications of an EP study are the same as those that can occur with cardiac catheterization. Because an artery is not always used, there is a lower incidence of vascular complications than with other catheterization procedures. Cardiac arrest may occur, but the incidence is low (less than 1%). Patients who are to undergo an EP study may be anxious about the procedure and about its outcome. A detailed discussion involving the patient, the family, and the electrophysiologist usually occurs to ensure that the patient is able to give informed consent and to reduce anxiety about the procedure. Before the procedure, patients should receive instructions about the procedure and its usual duration, the environment where the procedure is performed, and what to expect. Although an EP study is not painful, it does cause discomfort and can be tiring. It may also cause feelings that were experienced when the dysrhythmia occurred in the past. In addition, patients also are taught what will be expected of them (eg, lying very still during the procedure, reporting symptoms or concerns). Patients need to know that the dysrhythmia may occur during the procedure, but under very controlled circumstances. It often stops on its own; if it does not, treatment is given to restore the patient’s normal rhythm. During the procedure, patients benefit from a calm, reassuring approach. Postprocedural care includes restriction of activity to promote hemostasis at the insertion site. To identify any complications and to ensure healing, the patient’s vital signs and the appearance of the insertion site are assessed frequently.
CARDIAC CONDUCTION SURGERY Atrial tachycardias and ventricular tachycardias that do not respond to medications and are not suitable for antitachycardia pacing may be treated by methods other than medications and devices. Such methods include endocardial isolation, endocardial resection, and ablation. An ICD may be used with these surgical interventions.
Endocardial Isolation Endocardial isolation involves making an incision into the endocardium that separates the area where the dysrhythmia originates from the surrounding endocardium. The edges of the incision are then sutured together. The incision and its resulting scar tissue prevent the dysrhythmia from affecting the whole heart.
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Endocardial Resection In endocardial resection, the origin of the dysrhythmia is identified, and that area of the endocardium is peeled away. No reconstruction or repair is necessary.
Catheter Ablation Therapy Catheter ablation destroys specific cells that are the cause or central conduction method of a tachydysrhythmia. It is performed with or after an EP study. Usual indications for ablation are AV nodal reentry tachycardia, atrial fibrillation, or VT unresponsive to previous therapy (or for which the therapy produced significant side effects). Ablation is also indicated to eliminate accessory AV pathways or bypass tracts that exist in the hearts of patients with preexcitation syndromes such as Wolff-Parkinson-White (WPW) syndrome. During normal embryonic development, all connections between the atrium and ventricles disappear, except for that between the AV node and the bundle of His. In some people, embryonic connections of normal heart muscle between the atrium and ventricles remain, providing an accessory pathway or a tract through which the electrical impulse can bypass the AV node. These pathways can be located in several different areas. If the patient develops atrial fibrillation, the impulse may be conducted into the ventricle at a rate of 300 times per minute or more, which can lead to ventricular fibrillation and sudden cardiac death. Preexcitation syndromes are identified by specific ECG findings. For example, in WPW syndrome there is a shortened PR interval, slurring (called a delta wave) of the initial QRS deflection, and prolonged QRS duration (Fig. 27-33). Ablation may be accomplished by three different methods: radiofrequency ablation, cryoablation, or electrical ablation. The most often used method is radiofrequency, which involves placing a special catheter at or near the origin of the dysrhythmia. High-frequency, low-energy sound waves are passed through the catheter, causing thermal injury and cellular changes that result in localized destruction and scarring. The tissue damage is more specific to the dysrhythmic tissue, with less trauma to the surrounding cardiac tissue than occurs with cryoablation or electrical ablation. Cryoablation involves placing a special probe, cooled to a temperature of −60°C (−76°F), on the endocardium at the site of the dysrhythmia’s origin for 2 minutes. The tissue freezes and is later replaced by scar tissue, eliminating the origin of the dysrhythmia. In electrical ablation, a catheter is placed at or near the origin of the dysrhythmia, and one to four shocks of 100 to 300 joules are administered through the catheter directly to the endocardium and surrounding tissue. The cardiac tissue burns and scars, thus eliminating the source of the dysrhythmia. During the ablation procedure, defibrillation pads, an automatic blood pressure cuff, and a pulse oximeter are used on the patient, and an indwelling urinary catheter is inserted. The patient is given light sedation. An EP study is performed and attempts to induce the dysrhythmia are made. The ablation catheter is placed at the origin of the dysrhythmia, and the ablation procedure is performed. Multiple ablations may be necessary. Successful ablation is achieved when the dysrhythmia can no longer be induced. The patient is monitored for another 30 to 60 minutes and then retested to ensure that the dysrhythmia will not recur. Postprocedural care is similar to that for an EP study, except that the patient is monitored more closely, depending on the time needed for recovery from sedation.
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Unit 6
CARDIOVASCULAR, CIRCULATORY, AND HEMATOLOGIC FUNCTION PR interval QRS
FIGURE 27-33
Wolff-Parkinson-White syndrome. (A) Sinus rhythm. Note the short PR interval, slurred initial upstroke of the QRS complex (delta wave, at the arrow), and prolonged QRS duration, upper lead II, lower lead V1. (B) Rhythm strip of same patient following ablation, upper lead V1, lower lead II. ECG strips courtesy of Linda Ardini and Catherine Berkmeyer, Inova Fairfax Hospital, Falls Church, VA.
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Critical Thinking Exercises
1.
You are caring for a 40 year-old male physician who had experienced a cardiac arrest at home, witnessed by his 9-yearold son and 15-year-old daughter. After having an ICD implanted, he appears sullen and withdrawn. On inquiry about how he feels, he replies, “I don’t know if this device is a blessing or a punishment!” How would you respond? What other factors are important to assess? Discuss the impact that his children may have on his perception of the device. How would you alter your plan of care to address this patient’s psychosocial concerns because he is a physician? How would the plan of care change if, instead of appearing sullen and withdrawn, he appeared irritable and confrontational?
2.
Your patient is an active 80-year-old woman who has heart failure and chronic atrial fibrillation. She is taking an angiotensin-converting enzyme inhibitor, a beta-blocker, a diuretic, and digoxin. During your assessment, she tells you that she felt very dizzy this morning. How would you focus your assessment, and why? Identify some of the key assessment factors. What nursing interventions are needed? How would you modify your assessment and interventions if your patient also had chronic obstructive pulmonary disease and renal insufficiency?
REFERENCES AND SELECTED READINGS Books and Pamphlets Albert, J. S. (2001). The AHA clinical cardiac consult. Philadelphia: Lippincott Williams & Wilkins. Braunwald, E., Zipes, D. P., & Libby, P. (2001). Heart disease: A textbook of cardiovascular medicine (6th ed.). Philadelphia: W. B. Saunders. Conover, M. B. (1998). Pocket guide to electrocardiology. St. Louis: Mosby. Ellenbogen, K. A., Kay, G. N, & Wilkoff, B. L. (Eds.). (2000). Clinical cardiac pacing and defibrillation (2nd ed.). Philadelphia: W. B. Saunders. Fuster, V., Alexander R. W., & O’Rourke, R. A. (Eds.). (2001). Hurst’s the heart (10th ed.). New York: McGraw-Hill. Kinney, M., Brooks-Brunn, J. A., Molter, N., Dunbar, S. B., & VitelloCiccio, L. M. (Eds.). (1998). AACN clinical reference for critical care nursing (4th ed.). St. Louis: Mosby. Management of new onset atrial fibrillation. Evidence Report/Technology Assessment: Number 12. AHRQ Publication No. 00-E007. (May 2000). Rockville, MD: Agency for Healthcare Research and Quality. Marriott, H. J., & Conover, M. B. (1998). Advanced concepts in arrhythmias. St. Louis: Mosby. McEvoy, G. K. (Ed.). (2001). AHFS drug information 2001. Bethesda, MD: American Society of Health System Pharmacists. McNamara, R. L., Bass, E. B., Miller, M. R., Kim, N. L., Robinson, K. A., & Powe, N. R. (2001). Management of new onset atrial fibrillation. Evidence Report/Technology Assessment No. 12 (prepared by the Johns Hopkins University Evidence-Based Practice Center in Baltimore, MD, under Contract No. 290-97-0006). AHRQ Publication Number 01-E026. Rockville, MD: Agency for Healthcare Research and Quality.
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Moses, H. W., Moulton, K. P., Miller, B. D., & Schneider, J. A. (2000). A practical guide to cardiac pacing (5th ed.). Philadelphia: Lippincott Williams & Wilkins. Murphy, J. (Ed.). (2000). Mayo Clinic cardiology review (2nd ed.). Philadelphia: Lippincott Williams & Wilkins. Singer, I. (2001). Interventional electrophysiology. Philadelphia: Lippincott. Skidmore-Roth, L. (2002). 2002 Mosby’s nursing drug reference. St Louis: Mosby. Wagner, G. S. (Ed.) (2001). Marriott’s practical electrocardiography (10th ed.). Philadelphia: Lippincott Williams & Wilkins.
Journals *Asterisks indicate nursing research articles. American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee on Pacemaker Implantation). (1998). ACC/AHA Task Force Report. Guidelines for implantation of cardiac pacemakers and antiarrhythmia devices: Executive summary. Circulation, 97(13), 1325–1335. American Heart Association, in collaboration with the International Liaison Committee on Resuscitation. (2000). Guidelines 2000 for cardiopulmonary resuscitation and emergency cardiovascular care: An international consensus on science. Circulation, 102, (8 Suppl.), I1–I384. Aronow, W. S. (1999). Management of the older person with ventricular arrhythmias. Journal of American Geriatrics Society, 47(7), 886–895. Asselin, M. E., & Cullen, H. A. (2001). What you need to know about the new ACLS guidelines: Find out about changes in algorithms and policies and how they’ll affect your practice. Nursing 2001, 31(4), 48–50. Atlee, J. L., & Bernstein, A. D. (2001). Cardiac rhythm management devices. Part I: Indications, device selection, and function. Anesthesiology, 95(5), 1265–1280. Atkins, D. L., Dorian, P., Gonzalez, E. R., Gorgel, A. P., Kudenchuk, P. J., Luriek, K. G., Morley, P. T., Robertson, C., Samson, R. A., Silka, M. J., & Singh, B. N. (2001). Treatment of tachyarrhythmias: Proceedings of the International Guidelines 2000 Conference for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Annuals of Emergency Medicine, 37(4), (Suppl.), S91–S109. Bernstein, J. E. (1997). Recognizing when long QT intervals mean trouble. Nursing 97, 27(4), 32aa–32ff. Boyle, J., & Rost, M. K. (2000). Present status of cardiac pacing: A nursing perspective. Critical Care Nursing Quarterly, 23(1), 1–19. Brown, J., & Kellerman, A. L. (2000). The shocking truth about automated external defibrillators. Journal of the American Medical Association, 284(11), 1438–1441. Bubien, R. S., & Sanchez, J. E. (2001). Atrial fibrillation: Treatment rationale and clinical utility of nonpharmacologic therapies. AACN Clinical Issues: Advanced Practice Acute Critical Care 12(1), 140–155. The Cardiac Arrhythmia Suppression Trial Investigators. (1989). The Cardiac Arrhythmia Suppression Trial. New England Journal of Medicine, 321(25), 1754–1756. Cannom, D. S. (2002). Implantable cardioverter defibrillator trials: What’s new? Current Opinion in Cardiology, 17(1), 29–35. Carroll, D. L., Hamilton, G. A., & McGovern, B. A. (1999). Changes in health status and quality of life and the impact of uncertainty in patients who survive life-threatening arrhythmia. Heart & Lung, 28(4), 251–260. Daoud, E. G., Timmermans, C., Fellows, C., Hoyt, R., Lemery, R., Dawson, K., & Ayers, G. M. (2000). Initial clinical experience with ambulatory use of an implantable atrial defibrillator for conversion of atrial fibrillation. Metrix Investigators. Circulation, 102(12), 1407–1413. Dickerson, S. S., Posluszny, M., & Kennedy, M. C. (2000). Help seeking in a support group for recipients of implantable cardioverter defibrillators and their support person. Heart & Lung, 29(2), 87–96. Dougherty, C. M., Benoliel, J. Q., & Bellin, C. (2000). Domains of nursing intervention after sudden cardiac arrest and automatic internal cardioverter defibrillator implantation. Heart & Lung, 29(2), 79–86. Drew, B. J., & Krucoff, M. W. (1999). Multilead ST-segment monitoring in patients with acute coronary syndromes: A consensus statement for healthcare professionals. American Journal of Critical Care, 8(6), 372–386.
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Fenton, J. M. (2001). The clinician’s approach to evaluating patients with dysrhythmias. AACN Clinical Issues: Advanced Practice Acute Critical Care, 12(1), 72–86. Gilbert, C. J. (2001). Common supraventricular tachycardias: Mechanisms and management. AACN Clinical Issues: Advanced Practice Acute Critical Care, 12(1), 100–113, 170–172. Gregoratos, G., Abrams, J., Epstein, A. E., Freedman, R. A., Hayes, D. L., Hlatky, M. A., Kerber, R. E., Naccarelli, G. V., Schoenfeld, M. H., Silka, M. J., Winters, S. L., Gibbons, R. J., Antman, E. M., Alpert, J. S., Gregoratos, G., Hiratzka, L. F., Faxon, D. P., Jacobs, A. K., Fuster, V., & Smith, S. C., Jr. ACC/AHA/NASPE 2002 guideline update for implantation of cardiac pacemakers and antiarrhythmia devices: Summary article. A report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (ACC/AHA/NASPE Committee to Update the 1998 Pacemaker Guidelines). Circulation, 106(16), 2145–2161. Hauptman, P. J., & Kelly, R. A. (1999). Digitalis. Circulation, 99(9), 1265–1270. Kellen, J. C., Ettinger, A., Todd, L., Brezsnyak, M. L., Campion, J., McBride, R., Thomas, S., Corum, J., & Schron, E. (1996). The cardiac arrhythmia suppression trial: Implications for nursing practice. American Journal of Critical Care, 5(1), 19–25. *Malm, D., Karlsson, J., & Fridlund, B. (1998). Quality of life in pacemaker patients from a nursing perspective. Coronary Health Care, 2(1), 17–27. Mirowski M., Mower M. M., & Reid, P. R. (1980). The automatic implantable defibrillator. American Heart Journal, 100, (6 Part II), 1089–1092. Ocampo, C. M. (2000). Living with an implantable cardioverter defibrillator: Impact on the patient, family and society. Nursing Clinics of North America, 35(4), 1019–1030. Reynolds, J., & Apple, S. (2001). A systematic approach to pacemaker assessment. AACN Clinical Issues: Advanced Practice Acute Critical Care, 12(1), 14–26. Shaffer, R. S. (2002). ICD therapy: The patient’s perspective. American Journal of Nursing, 102(2), 46–49. Thomas, S. A., Friedmann, E., & Kelley, F. J. (2001). Living with an implantable cardioverter-defibrillator: A review of the current literature related to psychosocial factors. AACN Clinical Issues: Advanced Practice Acute Critical Care, 12(1), 156–163. *Tyndall, A., Nystrom, K. V., & Funk, M. (1997). Nausea and vomiting in patients undergoing radiofrequency catheter ablation. American Journal of Critical Care, 6(6), 437–444. Wallace, C. J. (2001). Diagnosing and treating pacemaker syndrome. Critical Care Nurse, 21(1), 24–31, 35–37. White, E. (2000). Patients with implantable cardioverter defibrillators: Transition to home. Journal of Cardiovascular Nursing, 14(3), 42–52. Yager, M., Benson, J., & Kamajian, M. (2001). Brugada syndrome: A case study of aborted sudden cardiac death manifesting as seizures. Critical Care Nurse, 21(1), 38, 40, 42–46. Zipes, D. P., & Wellens, H. J. (2000). What have we learned about cardiac arrhythmias? Circulation, 102, (20 Suppl. 4), IV52–IV57.
RESOURCES AND WEBSITES American Association of Critical Care Nurses, 101 Columbia, Aliso Viejo, CA 92656-4109; 800-899-2226; http://www.aacn.org. American College of Cardiology, 911 Old Georgetown Road, Bethesda, MD 20814; 800-253-4636; http://www.acc.org. American Heart Association, National Center, 7272 Greenville Ave., Dallas, TX 75231; 1-800-242-8721; http://www.americanheart.org. National Heart, Lung, Blood Institute, Health Information Center, National Institutes of Health, PO Box 30105, Bethesda, MD 20824; 301-592-8573; http://www.nhlbi.nih.gov. National Institute on Aging, Building 31, Room 5C27, 31 Center Drive, MSC 2292, Bethesda, MD 20892; 301-496-1752; http:// www.nih.gov/nia. North American Society of Pacing and Electrophysiology, Six Strathmore Road, Natick, MA 01760-2499; 508-647-0100; http://www. naspe.org.
Chapter
28 ●
Management of Patients With Coronary Vascular Disorders
LEARNING OBJECTIVES
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On completion of this chapter, the learner will be able to: 1. Describe the pathophysiology, clinical manifestations, and treatment 2. 3. 4. 5. 6. 7. 8.
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of coronary atherosclerosis. Describe the pathophysiology, clinical manifestations, and treatment of angina pectoris. Use the nursing process as a framework for care of patients with angina pectoris. Describe the pathophysiology, clinical manifestations, and treatment of myocardial infarction. Use the nursing process as a framework for care of patients with myocardial infarction (acute coronary syndrome). Describe the nursing care of a patient who has had an invasive interventional procedure for treatment of coronary artery disease. Describe coronary artery revascularization procedures. Describe the nursing care of the patient treated with cardiac surgery.
I
Chapter 28
n the past, identification and treatment of heart disease focused on white, middle-aged men. However, later studies showed that other segments of the population were also seriously affected by cardiac conditions. Cardiovascular disease is the leading cause of death in the United States for men and women of all racial and ethnic groups, and more women die of cardiovascular disease than all types of cancers combined (American Heart Association, 2001).
Coronary Artery Disease Coronary artery disease (CAD) is the most prevalent type of cardiovascular disease. For this reason, it is important for nurses to become familiar with the various types of coronary artery conditions and the methods for assessing, preventing, and treating these disorders medically and surgically.
CORONARY ATHEROSCLEROSIS The most common heart disease in the United States is atherosclerosis, which is an abnormal accumulation of lipid, or fatty, substances and fibrous tissue in the vessel wall. These substances create blockages or narrow the vessel in a way that reduces blood flow to the myocardium. Studies (Mehta et al., 1998) indicate that atherosclerosis involves a repetitious inflammatory response to artery wall injury and an alteration in the biophysical and biochemical properties of the arterial walls. An association between an infection (eg, gingivitis) and the later development of heart disease is being explored, as is the administration of antibiotics to prevent heart disease. Although authorities disagree about how atherosclerosis begins, they agree that atherosclerosis is a progressive disease that can be curtailed and, in some cases, reversed.
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Pathophysiology Atherosclerosis begins as fatty streaks, lipids that are deposited in the intima of the arterial wall. Although they are thought to be the precursors of atherosclerosis, fatty streaks are common, even in childhood. Moreover, not all develop into more advanced lesions. The reason why some fatty streaks continue to develop is unknown, although genetic and environmental factors are involved. The continued development of atherosclerosis involves an inflammatory response. T lymphocytes and monocytes (that become macrophages) infiltrate the area to ingest the lipids and then die; this causes smooth muscle cells within the vessel to proliferate and form a fibrous cap over the dead fatty core. These deposits, called atheromas or plaques, protrude into the lumen of the vessel, narrowing it and obstructing blood flow (Fig. 28-1). If the fibrous cap of the plaque is thick and the lipid pool remains relatively stable, it can resist the stress from blood flow and vessel movement. If the cap is thin, the lipid core may grow, causing it to rupture and hemorrhage into the plaque, allowing a thrombus to develop. The thrombus may obstruct blood flow, leading to sudden cardiac death or an acute myocardial infarction (MI), which is the death of heart tissue. The anatomic structure of the coronary arteries makes them particularly susceptible to the mechanisms of atherosclerosis. As Figure 28-2 shows, they twist and turn as they supply blood to the heart, creating sites susceptible to atheroma development. Although heart disease is most often caused by atherosclerosis of the coronary arteries, other phenomena decrease blood flow to the heart. Examples include vasospasm (sudden constriction or narrowing) of a coronary artery, myocardial trauma from internal or external forces, structural disease, congenital anomalies, decreased oxygen supply (eg, from acute blood loss, anemia, or low
Glossary ACE inhibitor (ACE-I): abbreviation for medications that inhibit the angiotensinconverting enzyme acute coronary syndrome (ACS): signs and symptoms that indicate unstable angina or acute myocardial infarction angina pectoris: chest pain brought about by myocardial ischemia atherosclerosis: abnormal accumulation of lipid deposits and fibrous tissue within arterial walls and lumen atheroma: fibrous cap composed of smooth muscle cells that forms over lipid deposits within arterial vessels and that protrudes into the lumen of the vessel, narrowing the lumen and obstructing blood flow; also called plaque collateral circulation: arteries that supply blood to tissue when the main arterial blood supply is partially or totally obstructed contractility: ability of the cardiac muscle to shorten in response to an electrical impulse coronary artery bypass graft (CABG): a surgical procedure in which a blood vessel from another part of the body is grafted onto the occluded coronary artery below the occlusion in such a way that blood flow bypasses the blockage
creatine kinase (CK): an enzyme found in human tissues; one of the three types of CK is specific to heart muscle and may be used as an indicator of heart muscle injury high-density lipoprotein (HDL): a proteinbound lipid that transports cholesterol to the liver for excretion in the bile; composed of a higher proportion of protein to lipid than low-density lipoprotein; exerts a beneficial effect on the arterial wall hormone replacement therapy (HRT): estrogen, progesterone, or both prescribed for postmenopausal or oophorectomized women ischemia: insufficient tissue oxygenation low-density lipoprotein (LDL): a proteinbound lipid that transports cholesterol to tissues in the body; composed of a lower proportion of protein to lipid than highdensity lipoprotein; exerts a harmful effect on the arterial wall myocardial infarction (MI): death of heart tissue caused by lack of oxygenated blood flow; if acute, abbreviated as AMI percutaneous coronary intervention (PCI): an invasive procedure in which a catheter is placed in a coronary artery, and one of
several methods is employed to remove or reduce a blockage within the artery percutaneous transluminal coronary angioplasty (PTCA): a type of percutaneous coronary intervention in which a balloon is inflated within a coronary artery to break an atheroma and open the vessel lumen, improving coronary artery blood flow primary prevention: interventions taken to prevent the development of coronary artery disease secondary prevention: interventions taken to prevent the advancement of existing coronary artery disease streptokinase (SK): a thrombolytic agent stent: a woven mesh that provides structural support to a coronary vessel, preventing its closure sudden cardiac death: immediate cessation of effective heart activity thrombolytic: an agent or process that breaks down blood clots troponin: myocardial protein; measurement is used to indicate heart muscle injury vasoconstrictor: an agent (usually a medication) that narrows the blood vessel lumen vasodilator: an agent (usually a medication) that enlarges blood vessel lumen
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Physiology/Pathophysiology Adventitia Media Intima
Fibrous cap Thrombus
Plaque
FIGURE 28-1
Atherosclerosis involves a normally patent artery (A) and an inflammatory response whereby smooth muscle cells proliferate within the blood vessel to form a fibrous cap (B). The proliferation results in deposits, called atheromas or plaques, which protrude into the lumen of the vessel, narrowing it and obstructing blood flow. If the cap ruptures and hemorrhages into the plaque (C), a thrombus (D) may develop and obstruct blood flow further.
blood pressure), and increased demand for oxygen (eg, from rapid heart rate, thyrotoxicosis, or ingestion of cocaine).
Clinical Manifestations Coronary atherosclerosis produces symptoms and complications according to the location and degree of narrowing of the arterial lumen, thrombus formation, and obstruction of blood flow to the myocardium. This impediment to blood flow is usually progressive, causing an inadequate blood supply that deprives the muscle cells of oxygen needed for their survival. The condition is known as ischemia. Angina pectoris refers to chest pain that is brought about by myocardial ischemia. Angina pectoris usually is caused by significant coronary atherosclerosis. If the decrease in blood supply is great enough, of long enough duration, or both, irreversible damage and death of myocardial cells, or MI, may result. Over time, irreversibly damaged myocardium undergoes degener-
ation and is replaced by scar tissue, causing various degrees of myocardial dysfunction. Significant myocardial damage may cause inadequate cardiac output, and the heart cannot support the body’s needs for blood, which is called heart failure (HF). A decrease in blood supply from CAD may even cause the heart to stop abruptly, an event that is called sudden cardiac death. The most common manifestation of myocardial ischemia is acute onset of chest pain. However, an epidemiologic study of the people in Framingham, Massachusetts, showed that nearly 15% of men and women who had MIs were totally asymptomatic (Kannel, 1986). Another study found that 33% of those diagnosed with MI did not present to the emergency room with chest pain (Canto et al., 2000; Ishihara et al., 2000). Those without chest pain tend to be older or women, or to have diabetes or a history of heart failure. Women have been found to have more atypical symptoms of myocardial ischemia (eg, shortness of breath, nausea, unusual fatigue) than men (Meischke et al., 1999). The incidence of prodromal angina (ie, angina a few hours to days before the MI) was found to be significantly lower in patients older than 70 years of age (Ishihara et al., 2000). Other clinical manifestations of CAD may be abnormalities signaled by changes on the electrocardiogram (ECG), high levels of cardiac enzymes, dysrhythmias, and sudden death.
Risk Factors
FIGURE 28-2 Angles of the coronary arteries. The many angles and curves of the coronary arteries contribute to the vessels’ susceptibility to atheromatous plaques. Arteries shown as dashed lines supply the posterior wall of the heart.
Epidemiologic studies point to several factors that increase the probability that heart disease will develop. Major risk factors include use of tobacco, hypertension, elevated blood lipid levels, family history of premature cardiovascular disease (first-degree relative with cardiovascular disease at age 55 or younger for men and at age 65 or younger for women) and age (>45 years for men; >55 years for women). The Third Report of the Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel III [ATP III]; 2001) represents the updated clinical guidelines for cholesterol testing and management. ATP III addresses primary prevention (preventing the occurrence of CAD) and secondary prevention (preventing the progression of CAD). ATP III is the standard for cholesterol management. ATP III continues to identify elevated low-density lipoprotein (LDL)
Chapter 28 cholesterol as the primary target of cholesterol-lowering therapy. Those at highest risk for having a cardiac event within 10 years are those with existing CAD or those with diabetes, peripheral arterial disease, abdominal aortic aneurysm, or carotid artery disease. The latter diseases are called CAD risk equivalents, because patients with these diseases have the same risk for a cardiac event as patients with CAD (Chart 28-1). The possibility of having a cardiac event within 10 years is also determined by points given to several factors, such as age, level of total cholesterol, level of LDL, level of high-density lipoprotein (HDL), systolic blood pressure, and tobacco use. If the total points add up to more than 15 for men or 23 for women, the person has a greater than 20% risk for a cardiac event within 10 years. A composite of lipid and nonlipid risk factors of metabolic origin, called metabolic syndrome, is another risk factor for CAD. Metabolic syndrome includes abdominal obesity, an elevated triglyceride level, low HDL level, elevated blood pressure, and impaired function of insulin. Measurement of other emerging risk factors, such as elevations of Lipoprotein(a) [Lp(a)], remnant lipoproteins, small LDL, fibrinogen, homocysteine, and impaired fasting plasma glucose (110–125 mg/dL), is optional and are not routinely recommended (ATP III, 2001). For example, the Homocysteine Studies Collaboration (2002) found that lower levels of homocysteine, an amino acid, were modestly associated with reduced risk of ischemic heart disease and stroke. The results of these retrospective studies suggest that homocysteine may promote atherosclerosis. A meta-analysis of prospective studies was done that showed a significant association between homocysteine levels and ischemic heart disease as well as between homocysteine and stroke (Wald, Law, & Morris, 2002). The authors recommend a daily intake of approximately 0.8 mg of folic acid to decrease blood homocysteine levels and reduce the risk of ischemic heart disease and CVA (brain attack, stroke). The American Heart Association has stated that until the results of large-scale randomized trials become available, routine testing of homocysteine concentrations cannot be justified (Malinow, Bostom, & Krauss, 1999).
Prevention Four modifiable risk factors—cholesterol abnormalities, cigarette smoking (tobacco use), hypertension, and diabetes mellitus— have been cited as major risk factors for CAD and its consequent complications. As a result, they receive much attention in health promotion programs (Chart 28-2).
Chart 28-1
Coronary Artery Disease Risk Equivalents
Individuals at highest risk for a cardiac event within 10 years are those with existing coronary artery disease (CAD) and those with any of the following diseases, which are called CAD risk equivalents: • Diabetes • Peripheral arterial disease • Abdominal aortic aneurysm • Carotid artery disease From Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults. (2001). Executive summary of the third report of the National Cholesterol Education Program (NCEP) Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel III). Journal of the American Medical Association, 285(19), 2486–2497.
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Chart 28-2
Risk Factors for Coronary Artery Disease A modifiable risk factor is one over which individuals may exercise control, such as by changing a lifestyle or personal habit or by using medication. A nonmodifiable risk factor is a circumstance over which individuals have no control, such as age or heredity. A risk factor may operate independently or in tandem with other risk factors. The more risk factors individuals have, the greater the likelihood of coronary artery disease. Those at risk are advised to seek regular medical examinations and to engage in “heart-healthy” behavior (a deliberate effort to reduce the number and extent of risks). Nonmodifiable Risk Factors Family history of coronary heart disease Increasing age Gender (heart disease occurs three times more often in men than in premenopausal women) Race (higher incidence of heart disease in African Americans than in Caucasians) Modifiable Risk Factors High blood cholesterol level Cigarette smoking, tobacco use Hypertension Diabetes mellitus Lack of estrogen in women Physical inactivity Obesity
CONTROLLING CHOLESTEROL ABNORMALITIES The association of a high blood cholesterol level with heart disease is well established and accepted. The metabolism of fats is important in understanding the development of heart disease. Fats, which are insoluble in water, are encased in water-soluble lipoproteins to allow them to be transported within a circulatory system that is water-based. Four elements of fat metabolism—total cholesterol, LDL, HDL, and triglycerides—are primary factors affecting the development of heart disease (Fig. 28-3). Cholesterol and the lipoproteins are synthesized by the liver or ingested as part of the diet. All adults 20 years of age or older should have a fasting lipid profile (total cholesterol, LDL, HDL, and triglyceride) performed at least once every 5 years and more often if the profile is abnormal. Patients who have had an acute event (MI), percutaneous coronary intervention (PCI), or coronary artery bypass graft (CABG) require assessment of the LDL-cholesterol level within 60 to 365 days after the event (LDL levels may be low immediately after the acute event). Subsequently, lipids should be monitored every 6 weeks until the desired level is achieved and then every 4 to 6 months (Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults, 2001). LDL exerts a harmful effect on the arterial wall and accelerates atherosclerosis. In contrast, HDL promotes the use of total cholesterol by transporting LDL to the liver, where it is biodegraded and then excreted. The desired goal is to have low LDL values and high HDL values. The desired level of LDL depends on the patient:
• Less than 160 mg/dL for patients with one or no risk factors • Less than 130 mg/dL for patients with two or more risk factors
• Less than 100 mg/dL for patients with CAD or a CAD risk equivalent
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Lipids
Cholesterol
VLDL
LDL
Triglycerides
HDL
Fatty Acids
Unsaturated
Monounsaturated
Saturated
Polyunsaturated
FIGURE 28-3 Types of lipids. Elevated levels of cholesterol, VLDL, LDL, and triglycerides, and low levels of HDL are risk factors for the development of atherosclerotic arterial disease, such as coronary artery disease. (VLDL, very low density lipoproteins; LDL, low density lipoproteins; HDL, high density lipoproteins.)
Serum cholesterol and LDL levels can usually be controlled by diet and physical activity. Depending on the patient’s LDL level and risk of coronary heart disease, medication therapy may also be prescribed. The level of HDL should exceed 40 mg/dL and should ideally be more than 60 mg/dL. A high HDL level is a strong negative risk factor (is protective) for heart disease. Triglyceride is another fatty substance, made up of fatty acids, that is transported through the blood by a lipoprotein. Although an elevated triglyceride level (>200 mg/dL) may be genetic in origin, it also can be caused by obesity, physical inactiv-
Table 28-1
ity, excessive alcohol intake, high-carbohydrate diets, diabetes mellitus, kidney disease, and certain medications, such as birth control pills, corticosteroids, and beta-adrenergic blockers when given in higher doses. Management of elevated triglyceride focuses on weight reduction and increased physical activity. Medications such as nicotinic acid and fibric acids (eg, fenofibrate [Tricor], clofibrate [Atromid-S]) may also be prescribed, especially if the triglyceride level is above 500 mg/dL (Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults, 2001). Lipoprotein(a), or Lp(a), is a component of LDL and is attached to a special protein called apo(a). The level of Lp(a) is primarily determined by genetics. An elevated level of Lp(a) has been associated with a higher risk of CAD. However, clinical trials have not yet identified methods that lower the level of Lp(a) and have not demonstrated that lower levels of Lp(a) reduce the risk of CAD; therefore Lp(a) is not routinely monitored (Danesh, et al., 2000; Gibbons et al., 1999). Dietary Measures. Table 28-1 provides recommendations of the Therapeutic Lifestyle Changes (TLC) diet (Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults, 2001). However, these recommendations may need to be adjusted to match the individual patient who has other nutritional needs, such as the requirements for pregnancy or diabetes. To assist in following the appropriate TLC diet, the patient should be referred to a registered dietitian. Other TLC recommendations are weight loss, cessation of tobacco use, and increased physical activity. Soluble dietary fiber may also help lower cholesterol levels. Soluble fibers, which are found in fresh fruit, cereal grains, vegetables, and legumes, enhance the excretion of metabolized cholesterol. The ability of fiber to reduce serum cholesterol continues to be investigated. Intake of at least 20 to 30 grams of fiber each day is recommended (Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults, 2001). Many resources are available to assist people who are attempting to control their cholesterol levels. The National Heart, Lung, and Blood Institute (NHLBI) and its National Cholesterol Education Program (NCEP), the American Heart Association, and the
• Nutrient Content of the Therapeutic Lifestyle Changes (TLC) Diet
NUTRIENT
RECOMMENDED INTAKE
Total calories* Total Fat Saturated fat† Polyunsaturated Fat Monounsaturated Fat Carbohydrate‡ Fiber Protein Cholesterol
Balance intake and expenditure to maintain desirable weight 25%–35% of total calories 200 mg/dL
HMG-CoA, 3-hydroxy-3-methylglutaryl coenzyme A; LDL, low-density lipoprotein; HDL, high-density lipoprotein; TG, triglycerides; ↓ decrease, ↑ increase; CHD, coronary heart disease *Cyclosporine (Neoral, Sandimmune, SangCya); macrolide antibiotics (azithromycin [Zithromax], clarithromycin [Biaxin]; dirithromycin [Dynabac]; erythromycin [Aknemycin, E-mycin, Ery-Tab]; various antifungal agents and cytochrome P-450 inhibitors; fibrates; and niacin should be used with appropriate caution). From Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults. (2001). Executive summary of the third report of the National Cholesterol Education Program (NCEP) Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel III). Journal of the American Medical Association, 285(19), 2486–2497.
these medications significantly increase the risk of CAD and sudden cardiac death. Cessation of tobacco use results in a lower rate of cardiac events. Patients should be advised to participate in an educational class, support group, or behavioral program. Use of medications such as the nicotine patch (Nicotrol, Nicoderm CQ, Habitrol) or bupropion (Zyban) may assist with stopping use of tobacco, but do have the same systemic effects: catecholamine release (increasing heart rate and blood pressure) and increased platelet adhesion. These medications should be used for the shortest time and at the lowest effective doses. MANAGING HYPERTENSION Hypertension is defined as blood pressure measurements that repeatedly exceed 140/90 mm Hg. Long-standing elevated blood pressure may result in increased stiffness of the vessel walls, leading to vessel injury and a resulting inflammatory response within
the intima. Hypertension can also increase the work of the left ventricle, which must pump harder to eject blood into the arteries. Over time, the increased workload causes the heart to enlarge and thicken (ie, hypertrophy), a condition that may eventually lead to cardiac failure. Early detection of high blood pressure and adherence to a therapeutic regimen can prevent the serious consequences associated with untreated elevated blood pressure. Hypertension is discussed in detail in Chapter 32. CONTROLLING DIABETES MELLITUS The relationship between diabetes mellitus and heart disease has been substantiated. For 65% to 75% of patients with diabetes, cardiovascular disease is listed as the cause of death (Braunwald et al., 2001; Grundy et al., 1999). Hyperglycemia fosters dyslipidemia, increased platelet aggregation, and altered red blood cell function, which can lead to thrombus formation. It has been suggested that
Chapter 28 these metabolic alterations impair endothelial cell–dependent vasodilation and smooth muscle function; treatment with insulin (eg, Humalog, Humulin, Novolin) and metformin (Glucophage) has demonstrated improvement in endothelial function: improved endothelial-dependent dilation (Gaenzer et al., 2002). Diabetes is considered equivalent to existing CAD in its risk of a cardiac event within 10 years (Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults, 2001). Diabetes is discussed in detail in Chapter 41.
Gender and Estrogen Level Because heart disease had been considered to primarily affect white men, the disease was not as readily recognized and treated in women. However, in 1999 in the United States, 512,904 women died because of cardiovascular disease whereas 42,144 women died from breast cancer and 246,006 women died from any form of cancer (American Heart Association, 2002). Women tend to have a higher incidence of complications from CAD (American Heart Association, 2002). African-American women have a mortality rate nearly twice that of Caucasian women (Office for Social Environment and Health Research at West Virginia University, 2001). Women tend not to recognize the symptoms as early as men and to wait longer to report their symptoms and seek medical assistance (Meischke et al., 1999; Penque et al., 1998). In the past, women were less likely than men to be referred for coronary artery diagnostic procedures, to receive medical therapy (eg, thrombolytic therapy to break down the blood clots that cause acute MI, or nitroglycerin), and to be treated with invasive interventions, eg, angioplasty (Sheifer et al., 2000). It is anticipated that with better education of the general public and health care professionals, gender and racial differences will have less influence on the diagnosis, treatment, and incidence of complications of heart disease in the future. In women younger than age 55, the incidence of CAD is significantly lower than in men. However, after age 55, the incidence in women is approximately equal to that in men. The age difference of the incidence of CAD in women may be related to estrogen. Although hormone replacement therapy (HRT) for menopausal women had been promoted as prevention for CAD, research studies do not support HRT as an effective means of CAD prevention (Hulley et al., 1998; Mosca, 2000). HRT has decreased postmenopausal symptoms and the risk for osteoporosisrelated bone fractures, but HRT also has been associated with an increased risk for CAD, breast cancer, deep vein thrombosis, cerebrovascular accident (CVA, brain attack, stroke), and pulmonary embolism. The Women’s Health Initiative (Gebbie, 2002) demonstrated that long-term HRT may have more risks than benefits, and that HRT should not be initiated or continued for primary prevention of CAD.
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& Rosenman, 1959; Krantz et al., 2000). A person with these behaviors is classified as type A coronary-prone. The type A coronary-prone classification may not be as significant as was once thought; evidence of its precise role remains inconclusive (Rozanski et al., 1999). To be on the safer side, however, such a person may be wise to alter behaviors and responses to triggering events and to reduce other risk factors. Nurses can assist these people by teaching them cognitive restructuring and relaxation techniques. Because people who are depressed have worse outcomes, these patients should be assessed for signs and symptoms of depression and, if diagnosed, appropriately treated.
ANGINA PECTORIS Angina pectoris is a clinical syndrome usually characterized by episodes or paroxysms of pain or pressure in the anterior chest. The cause is usually insufficient coronary blood flow. The insufficient flow results in a decreased oxygen supply to meet an increased myocardial demand for oxygen in response to physical exertion or emotional stress. In other words, the need for oxygen exceeds the supply. The severity of angina is based on the precipitating activity and its effect on the activities of daily living (Table 28-3).
Pathophysiology Angina is usually caused by atherosclerotic disease. Almost invariably, angina is associated with a significant obstruction of a major coronary artery. The characteristics of the various types of angina are listed in Chart 28-3. Identifying angina requires obtaining a thorough history. Effective treatment begins with reducing the demands placed on the heart and teaching the patient about the condition. Several factors are associated with typical anginal pain:
• Physical exertion, which can precipitate an attack by increasing myocardial oxygen demand
• Exposure to cold, which can cause vasoconstriction and an elevated blood pressure, with increased oxygen demand
• Eating a heavy meal, which increases the blood flow to the
•
mesenteric area for digestion, thereby reducing the blood supply available to the heart muscle (In a severely compromised heart, shunting of blood for digestion can be sufficient to induce anginal pain.) Stress or any emotion-provoking situation, causing the release of adrenaline and increasing blood pressure, which may accelerate the heart rate and increase the myocardial workload
Table 28-3
• Canadian Cardiovascular Society
Behavior Patterns
CLASS
ACTIVITY EVOKING ANGINA
LIMITS TO ACTIVITY
Most clinicians believe that stress and certain behaviors contribute to the pathogenesis of CAD and a cardiac event, especially in women. Psychological and epidemiologic studies describe behaviors that characterize people who are prone to heart disease: excessive competitiveness, a sense of time urgency or impatience, aggressiveness, and hostility (Dembroski et al., 1989; Friedman
I II III IV
Prolonged exertion Walking >2 blocks Walking 200 mm Hg Uncontrolled diabetes (BS > 400 mg/dL) Severe orthopedic problems Uncompensated symptomatic HF
Symptomatic severe aortic stenosis Active pericarditis, myocarditis High degree atrioventricular block Resting diastolic BP > 110 mm Hg Hypertrophic cardiomyopathy Active systemic illness or fever Orthostatic decrease in BP by ≥ 20 mm Hg with symptoms
CAD, coronary artery disease; BS, blood sugar; BP, blood pressure; HF, heart failure; HR, heart rate. Adapted from the American College of Cardiology Foundation and the American Heart Association (2002). ACC/AHA 2002 Guideline Update for Exercise Testing: A report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee on Exercise Testing). Available at: http://www.acc.org/clinical/guidelines/exercise. Accessed December 3, 2002.
patient is admitted to the hospital for ACS (unstable angina, acute MI). It consists of low-level activities and initial education for the patient and family. Because of the brief hospital stay, mobilization occurs earlier, and patient teaching is prioritized to the essentials of self-care, rather than instituting behavioral changes for risk reduction. Priorities for in-hospital education include the signs and symptoms that indicate the need to call 911 (seek emergency assistance), the medication regimen, rest-activity balance, and follow-up appointments with the physician. The nurse needs to reassure the patient that, although CAD is a lifelong disease and must be treated as such, most patients can resume a normal life after an MI. This positive approach while in the hospital helps to motivate and teach the patient to continue the education and lifestyle changes that are usually needed after discharge. The amount of activity recommended at discharge depends on the age of the patient, his or her condition before the cardiac event, the extent of the disease, the course of the hospital stay, and the development of any complications. Phase II occurs after the patient has been discharged. It usually lasts for 4 to 6 weeks but may last up to 6 months. This outpatient program consists of supervised, often ECG-monitored, exercise training that is individualized based on the results of an exercise stress test. Support and guidance related to the treatment of the disease and education and counseling related to lifestyle modification for risk factor reduction are a significant part of this phase. Short-term and long-range goals are collaboratively determined based on the patient’s needs. At each session, the patient is assessed for the effectiveness of and adherence to the current medical plan. To prevent complications and another hospitalization, the cardiac rehabilitation staff alerts the referring physician to any problems. Outpatient cardiac rehabilitation programs are designed to encourage patients and families to support each other. Many programs offer support sessions for spouses and significant others while the patients exercise. The programs involve group educational sessions for both patients and families that are given by cardiologists, exercise physiologists, dietitians, nurses, and other health care professionals. These sessions may take place outside a traditional classroom setting. For instance, a dietitian may take a group of patients and their families to a grocery store to examine labels and meat selections or to a restaurant to discuss menu offerings for a “heart-healthy” diet. Phase III focuses on maintaining cardiovascular stability and long-term conditioning. The patient is usually self-directed during this phase and does not require a supervised program, although it may be offered. The goals of each phase build on the accomplishments of the previous phase.
NURSING PROCESS: THE PATIENT WITH MYOCARDIAL INFARCTION Assessment One of the most important aspects of care of the patient with an MI is the assessment. It establishes the baseline for the patient so that any deviations may be identified, systematically identifies the patient’s needs, and helps determine the priority of those needs. Systematic assessment includes a careful history, particularly as it relates to symptoms: chest pain or discomfort, difficulty breathing (dyspnea), palpitations, unusual fatigue, faintness (syncope), or sweating (diaphoresis). Each symptom must be evaluated with regard to time, duration, the factors that precipitate the symptom and relieve it, and comparison with previous symptoms. A precise and complete physical assessment is critical to detect complications and any change in patient status. Chart 28-6 identifies important assessments and possible findings. Intravenous sites are examined frequently. At least one and possibly two intravenous lines are placed for any patient with ACS to ensure that access is available for administering emergency medications. Medications are administered intravenously to achieve rapid onset and to allow for timely adjustment. Intramuscular medications are avoided because of unpredictable absorption, delayed effect, and the risk of causing elevated serum enzyme levels by injuring muscle cells with an injection. After the patient’s condition stabilizes, the intravenous line may be changed into a saline lock to maintain intravenous access.
Diagnosis NURSING DIAGNOSES Based on the clinical manifestations, history, and diagnostic assessment data, the patient’s major nursing diagnoses may include: • Ineffective cardiopulmonary tissue perfusion related to reduced coronary blood flow from coronary thrombus and atherosclerotic plaque • Potential impaired gas exchange related to fluid overload from left ventricular dysfunction • Potential altered peripheral tissue perfusion related to decreased cardiac output from left ventricular dysfunction • Anxiety related to fear of death • Deficient knowledge about post-MI self-care
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COLLABORATIVE PROBLEMS/ POTENTIAL COMPLICATIONS Based on the assessment data, potential complications that may develop include the following:
• • • • • •
Acute pulmonary edema (see Chap. 30) Heart failure (see Chap. 30) Cardiogenic shock (see Chap. 30) Dysrhythmias and cardiac arrest (see Chaps. 27 and 30) Pericardial effusion and cardiac tamponade (see Chap. 30) Myocardial rupture (see Chap. 30)
Planning and Goals The major goals of the patient include relief of pain or ischemic signs and symptoms (eg, ST-segment changes), prevention of further myocardial damage, absence of respiratory dysfunction, maintenance or attainment of adequate tissue perfusion by decreasing the heart’s workload, reduced anxiety, adherence to the self-care program, and absence or early recognition of complications. Care of the patient with an uncomplicated MI is summarized in the Plan of Nursing Care on pages 731–733.
Nursing Interventions RELIEVING PAIN AND OTHER SIGNS AND SYMPTOMS OF ISCHEMIA Balancing the cardiac oxygen supply with its oxygen demand (eg, as evidenced by the relief of chest pain) is the top priority for the patient with an acute MI. Although medication therapy is required to accomplish this goal, nursing interventions are also important. Collaboration among the patient, nurse, and physician is critical in assessing the patient’s response to therapy and in altering the interventions accordingly. The accepted method for relieving symptoms associated with MI is revascularization with thrombolytic therapy or emergent PCI for patients who present to the health care facility immediately and who have no major contraindications. These therapies are important because, in addition to relieving symptoms, they aid in minimizing or avoiding permanent injury to the myocardium. With or without revascularization, administration of aspirin, intravenous beta-blocker, and nitroglycerin is indicated. Use of a GPIIb/IIIa agent or heparin may also be indicated. The nurse administers morphine for relief of pain and other symptoms, anxiety, and reduction of preload. Oxygen should be administered along with medication therapy to assist with relief of symptoms. Administration of oxygen even in low doses raises the circulating level of oxygen to reduce pain associated with low levels of myocardial oxygen. The route of administration, usually by nasal cannula, and the oxygen flow rate are documented. A flow rate of 2 to 4 L/min is usually adequate to maintain oxygen saturation levels of 96% to 100% if no other disease is present. Vital signs are assessed frequently as long as the patient is experiencing pain and other signs or symptoms of acute ischemia. Physical rest in bed with the backrest elevated or in a cardiac chair helps to decrease chest discomfort and dyspnea. Elevation of the head is beneficial for the following reasons: • Tidal volume improves because of reduced pressure from abdominal contents on the diaphragm and better lung expansion and gas exchange. • Drainage of the upper lung lobes improves. • Venous return to the heart (preload) decreases, which reduces the work of the heart.
IMPROVING RESPIRATORY FUNCTION Regular and careful assessment of respiratory function can help the nurse detect early signs of pulmonary complications. Scrupulous attention to fluid volume status prevents overloading the heart and lungs. Encouraging the patient to breathe deeply and change position frequently helps keep fluid from pooling in the bases of the lungs. PROMOTING ADEQUATE TISSUE PERFUSION Limiting the patient to bed or chair rest during the initial phase of treatment is particularly helpful in reducing myocardial oxygen consumption (mV⭈ O2). This limitation should remain until the patient is pain-free and hemodynamically stable. Checking skin temperature and peripheral pulses frequently is important to ensure adequate tissue perfusion. Oxygen may be administered to enrich the supply of circulating oxygen. REDUCING ANXIETY Alleviating anxiety and fears is an important nursing function to reduce the sympathetic stress response. Decreased sympathetic stimulation decreases the workload of the heart, which may relieve pain and other signs and symptoms of ischemia. Developing a trusting and caring relationship with the patient is critical in reducing anxiety. Providing information to the patient and family in an honest and supportive manner invites the patient to be a partner in care and greatly assists in developing a positive relationship. Ensuring a quiet environment, preventing interruptions that disturb sleep, using a caring and appropriate touch, teaching the patient the relaxation response, using humor and assisting the patient to laugh, and providing the appropriate prayer book and assisting the patient to pray if consistent with the patient’s beliefs are other nursing interventions that can be used to reduce anxiety. Frequent opportunities are provided for the patient to privately share concerns and fears. An atmosphere of acceptance helps the patient to know that these concerns and fears are both realistic and normal. Music therapy, in which the patient listens to selected music for a predetermined duration and at a set time, has been found to be an effective method for reducing anxiety and managing stress (Chlan & Tracy, 1999; Evans, 2002). Pet therapy, in which animals are brought to the patient, appears to provide emotional support and reduce anxiety. Administrative and infectious control practitioners are usually involved in developing standards for the animals, animal handlers, and patients who are eligible for pet therapy. MONITORING AND MANAGING POTENTIAL COMPLICATIONS Complications that can occur after acute MI are caused by the damage that occurs to the myocardium and to the conduction system as a result of the reduced coronary blood flow. Because these complications can be lethal, close monitoring for and early identification of the signs and symptoms is critical (see Plan of Nursing Care, pp. 731–733). The nurse monitors the patient closely for changes in cardiac rate and rhythm, heart sounds, blood pressure, chest pain, respiratory status, urinary output, skin color and temperature, sensorium, ECG changes, and laboratory values. Any changes in the patient’s condition are reported promptly to the physician, and emergency measures are instituted when necessary. PROMOTING HOME AND COMMUNITY-BASED CARE Teaching Patients Self-Care The most effective way to increase the probability the patient will implement a self-care regimen after discharge is to identify the (text continues on page 733)
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Plan of Nursing Care Care of the Patient With an Uncomplicated Myocardial Infarction Nursing Interventions
Rationale
Expected Outcomes
Nursing Diagnosis: Ineffective cardiopulmonary tissue perfusion related to reduced coronary blood flow Goal: Relief of chest pain/discomfort 1. Initially assess, document, and report to the physician the following: a. The patient’s description of chest discomfort, including location, intensity, radiation, duration, and factors that affect it. Other symptoms such as nausea, diaphoresis, or complaints of unusual fatigue. b. The effect of chest discomfort on cardiovascular perfusion—to the heart (eg, change in blood pressure, heart sounds), to the brain (eg, changes in LOC), to the kidneys (eg, decrease in urine output), and to the skin (eg, color, temperature). 2. Obtain a 12-lead ECG recording during the symptomatic event, as prescribed, to determine extension of infarction. 3. Administer oxygen as prescribed. 4. Administer medication therapy as prescribed and evaluate the patient’s response continuously. 5. Ensure physical rest: use of the bedside commode with assistance; backrest elevated to promote comfort; diet as tolerated; arms supported during upper extremity activity; use of stool softener to prevent straining at stool. Provide a restful environment, and allay fears and anxiety by being supportive, calm, and competent. Individualized visitation, based on patient response.
1. These data assist in determining the cause and effect of the chest discomfort and provide a baseline with which post-therapy symptoms can be compared. a. There are many conditions associated with chest discomfort. There are characteristic clinical findings of ischemic pain and symptoms.
• Reports beginning relief of chest discomfort and symptoms at once
• Appears comfortable and pain or symptom
• b. MI decreases myocardial contractility and ventricular compliance and may produce dysrhythmias. Cardiac output is reduced, resulting in reduced blood pressure and decreased organ perfusion. The heart rate may increase as a compensatory mechanism to maintain cardiac output. 2. An ECG during symptoms may be useful in the diagnosis of an extension of MI.
•
free: Is rested Respiratory rate, cardiac rate, and blood pressure return to prediscomfort level Skin warm and dry Adequate cardiac output as evidenced by: Heart rate and rhythm Blood pressure Mentation Urine output Serum BUN and creatinine Skin color, temperature, and moisture Is pain and symptom free
3. Oxygen therapy may increase the oxygen supply to the myocardium if actual oxygen saturation is less than normal. 4. Medication therapy is the first line of defense in preserving myocardial tissue. The side effects of these medications can be hazardous and the patient’s status must be assessed. 5. Physical rest reduces myocardial oxygen consumption. Fear and anxiety precipitate the stress response; this results in increased levels of endogenous catecholamines, which increase myocardial oxygen consumption. Also, with increased epinephrine, the pain threshold is decreased, and pain increases myocardial oxygen consumption.
Nursing Diagnosis: Potential ineffective air exchange related to fluid overload Goal: Absence of respiratory difficulties 1. Initially, every 4 hours, and with chest discomfort or symptoms, assess, document, and report to the physician abnormal heart sounds (particularly S3 and S4 gallops and the holosystolic murmur of left ventricular papillary muscle dysfunction), abnormal breath sounds (particularly crackles), and patient intolerance to specific activities.
1. These data are useful in diagnosing left ventricular failure. Diastolic filling sounds (S3 and S4 gallop) result from decreased left ventricular compliance associated with MI. Papillary muscle dysfunction (from infarction of the papillary muscle) can result in mitral regurgitation and a reduction in stroke volume, leading to left ventricular failure. The presence of crackles (usually at the lung bases) may indicate pulmonary
• No shortness of breath, dyspnea on exer• • • •
tion, orthopnea, or paroxysmal nocturnal dyspnea Respiratory rate less than 20 breaths/min with physical activity and 16 breaths/min with rest Skin color normal PaO2 and PaCO2 within normal range Heart rate less than 100 beats/min and greater than 60 beats/min, with blood pressure within patient’s normal limits (continued)
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Plan of Nursing Care Care of the Patient With an Uncomplicated Myocardial Infarction (Continued) Nursing Interventions
Rationale congestion from increased left heart pressures. The association of symptoms and activity can be used as a guide for activity prescription and a basis for patient teaching.
2. Teach patient: a. To adhere to the diet prescribed (for example, explain low-sodium, lowcalorie diet)
b. To adhere to activity prescription
Expected Outcomes • Chest x-ray normal • Relief of chest discomfort • Appears comfortable:
Appears rested Respiratory rate, cardiac rate, and blood pressure return to prediscomfort level Skin warm and dry
2. a. Low-sodium diet may reduce extracellular volume, thus reducing preload and afterload, and thus myocardial oxygen consumption. In the obese patient, weight reduction may decrease cardiac work and improve tidal volume. b. The activity prescription is determined individually to maintain the heart rate and blood pressure within safe limits.
Nursing Diagnosis: Potential ineffective peripheral tissue perfusion related to decreased cardiac output Goal: Maintenance/attainment of adequate tissue perfusion 1. Initially, every 4 hours, and with chest discomfort, assess, document, and report to the physician the following: a. Hypotension b. Tachycardia and other dysrhythmia c. Activity intolerance d. Mentation changes (use family input) e. Reduced urine output (less than 200 mL per 8 hours) f. Cool, moist, cyanotic extremities
1. These data are useful in determining a low cardiac output state. An ECG with pain may be useful in the diagnosis of an extension of myocardial ischemia, injury, and infarction, and of variant angina.
• Blood pressure within the patient’s normal range
• Ideally, normal sinus rhythm without
• • •
• •
dysrhythmia is maintained, or patient’s baseline rhythm is maintained between 60 and 100 beats/min without further dysrhythmia. No complaints of fatigue with prescribed activity Remains fully alert and oriented and without cognitive or behavioral change Appears comfortable Appears rested Respiratory rate, cardiac rate, and blood pressure return to prediscomfort level Skin warm and dry Urine output greater than 25 mL/hr Extremities warm and dry with normal color
Nursing Diagnosis: Anxiety related to fear of death, change in health status Goal: Reduction of anxiety 1. Assess, document, and report to the physician the patient’s and family’s level of anxiety and coping mechanisms.
1. These data provide information about the psychological well-being and a baseline so that post-therapy symptoms can be compared. Causes of anxiety are variable and individual, and may include acute illness, hospitalization, pain, disruption of activities of daily living at home and at work, changes in role and self-image due to chronic illness, and lack of financial support. Because anxious family members can transmit anxiety to the patient, the nurse must also identify strategies to reduce the family’s fear and anxiety.
• Reports less anxiety • Patient and family discuss their anxieties and fears about death
• Patient and family appear less anxious • Appears restful, respiratory rate less than
• •
16/min, heart rate less than 100/min without ectopic beats, blood pressure within patient’s normal limits, skin warm and dry Participates actively in a progressive rehabilitation program Practices stress reduction techniques
(continued)
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Plan of Nursing Care Care of the Patient With an Uncomplicated Myocardial Infarction (Continued) Nursing Interventions
Rationale
2. Assess the need for spiritual counseling and refer as appropriate.
2. If a patient finds support in a religion, religious counseling may assist in reducing anxiety and fear. 3. Unresolved anxiety (the stress response) increases myocardial oxygen consumption.
3. Allow patient (and family) to express anxiety and fear: a. By showing genuine interest and concern b. By facilitating communication (listening, reflecting, guiding) c. By answering questions 4. Use of flexible visiting hours allows the presence of a supportive family to assist in reducing the patient’s level of anxiety. 5. Encourage active participation in a cardiac rehabilitation program. 6. Teach stress reduction techniques.
Expected Outcomes
4. The presence of supportive family members may reduce both patient’s and family’s anxiety. 5. Prescribed cardiac rehabilitation may help to eliminate fear of death, reduce anxiety, and enhance feelings of wellbeing. 6. Stress reduction may help to reduce myocardial oxygen consumption and may enhance feelings of well-being.
Nursing Diagnosis: Deficient knowledge about post-MI self-care Goal: Adheres to the home health care program Chooses lifestyle consistent with heart-healthy recommendations. (See Chart 28-8, Promoting Health After MI)
priorities as perceived by the patient, provide adequate education about heart-healthy living, and facilitate the patient’s involvement in a cardiac rehabilitation program. Working with patients in developing plans to meet their specific needs further enhances the potential for an effective treatment plan (Chart 28-8).
Evaluation EXPECTED PATIENT OUTCOMES Expected patient outcomes may include the following: 1. 2. 3. 4. 5. 6.
Relief of angina No signs of respiratory difficulties Adequate tissue perfusion Decreased anxiety Adherence to a self-care program Absence of complications
Invasive Coronary Artery Procedures INVASIVE INTERVENTIONAL PROCEDURES Angina pectoris may persist for many years in a stable form with brief attacks. However, unstable angina is a serious condition that can progress to MI or sudden cardiac death (ACS). Invasive interventional procedures to treat angina and CAD are PTCA, intracoronary stent implantation, atherectomy, brachytherapy, and transmyocardial laser revascularization. All of these procedures are classified as percutaneous coronary interventions (PCIs).
Percutaneous Transluminal Coronary Angioplasty (PTCA) PTCA may be used to treat patients who do not experience angina but are at high risk for a cardiac event as identified by noninvasive testing, with recurrent chest pain that is unresponsive to medical therapy, with a significant amount of myocardium at risk but are poor surgical candidates, or with an acute MI (as an alternate to thrombolysis and after thrombolysis) (Smith et al., 2001). The procedure is attempted when the cardiologist believes that PTCA can improve blood flow to the myocardium. PTCA alone is seldom attempted in the patient with occlusions of the left main coronary artery that do not demonstrate collateral circulation to the left anterior descending and circumflex arteries. The purpose of PTCA is to improve blood flow within a coronary artery by “cracking” the atheroma. This invasive interventional procedure is carried out in the cardiac catheterization laboratory. The coronary arteries are examined by angiography, as they are during the diagnostic cardiac catheterization, and the location, extent, and calcification of the atheroma are verified. Hollow catheters, called sheaths, are inserted, usually in the femoral vein or artery (or both), providing a conduit for other catheters. After the presence of atheroma is verified, a balloon-tipped dilation catheter is passed through the sheath along a guide catheter and positioned over the lesion. The physician determines the catheter position by examining markers on the balloon that can be seen with fluoroscopy. When the catheter is properly positioned, the balloon is inflated with a radiopaque contrast agent (commonly called dye) to visualize the
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Chart 28-8 Promoting Health After Myocardial Infarction and Other Acute Coronary Syndromes To extend and improve the quality of life, a patient who has had an MI must learn to adjust his or her lifestyle to promote heart-healthy living. With this in mind, the nurse and patient develop a program to help the patient achieve desired outcomes. Changing Lifestyle During Convalescence and Healing Adaptation to a heart attack is an ongoing process and usually requires some modification of lifestyle. Some specific modifications include: • Avoiding any activity that produces chest pain, extreme dyspnea, or undue fatigue • Avoiding extremes of heat and cold and walking against the wind • Losing weight, if indicated • Stopping smoking and use of tobacco; avoiding second-hand smoke • Using personal strengths to support lifestyle changes • Developing heart-healthy eating patterns and avoiding large meals and hurrying while eating • Modifying meals to align with the Therapeutic Lifestyle Changes (TLC) or the Dietary Approaches to Stopping Hypertension (DASH) diet • Adhering to medical regimen, especially in taking medications • Following recommendations that ensure blood pressure and blood glucose are in control • Pursuing activities that relieve and reduce stress
blood vessel and to provide a steady or oscillating pressure within the balloon. The balloon is inflated to a certain pressure for several seconds and then deflated. The pressure “cracks” and possibly compresses the atheroma (Fig. 28-5). The coronary artery’s media and adventitia are also stretched.
A
Adopting an Activity Program Additionally, the patient needs to undertake an orderly program of increasing activity and exercise for long-term rehabilitation as follows: • Engaging in a regimen of physical conditioning with a gradual increase in activity duration and then a gradual increase in activity intensity • Walking daily, increasing distance and time as prescribed • Monitoring pulse rate during physical activity until the maximum level of activity is attained • Avoiding activities that tense the muscles: isometric exercise, weight-lifting, any activity that requires sudden bursts of energy • Avoiding physical exercise immediately after a meal • Alternating activity with rest periods (some fatigue is normal and expected during convalescence) • Participating in a daily program of exercise that develops into a program of regular exercise for a lifetime Managing Symptoms The patient must learn to recognize and take appropriate action for possible recurrences of symptoms as follows: • Call 911 if chest pressure or pain (or anginal equivalent) is not relieved in 15 minutes by nitroglycerin • Contacting the physician if any of the following occur: shortness of breath, fainting, slow or rapid heartbeat, swelling of feet and ankles
Several inflations and several balloon sizes may be required to achieve the desired goal, usually defined as an improvement in blood flow and a residual stenosis of less than 20%. Other gauges of the success of a PTCA are an increase in the artery’s lumen, a difference of less than 20 mm Hg in blood pressure from one side
Artery wall Atheroma (plaque) Catheter in place; balloon deflated
B
Balloon inflated
C Atheroma cracked; catheter removed
FIGURE 28-5 Percutaneous transluminal coronary angioplasty. (A) A balloon-tipped catheter is passed into the affected coronary artery and placed across the area of the atheroma (plaque). (B) The balloon is then rapidly inflated and deflated with controlled pressure. (C) After the atheroma is cracked, the catheter is removed, and blood flow improves.
Chapter 28 of the lesion to the other, and no clinically obvious arterial trauma. Because the blood supply to the coronary artery decreases while the balloon is inflated, the patient may complain of chest pain (often called stretch pain), and the ECG may display significant ST-segment changes (Jeremias et al., 1998). COMPLICATIONS Possible complications during the PTCA procedure include dissection, perforation, abrupt closure, or vasospasm of the coronary artery, acute MI, acute dysrhythmias (eg, ventricular tachycardia), and cardiac arrest. These may require emergency surgical treatment. Complications after the procedure may include abrupt closure and vascular complications, such as bleeding at the insertion site, retroperitoneal bleeding, hematoma, pseudoaneurysm, arteriovenous fistula, or arterial thrombosis and distal embolization (Table 28-7). POSTPROCEDURE CARE Patient care is similar to that for a cardiac catheterization (see Chapter 26). Many patients are admitted to the hospital the day of the PTCA. Those with no complications go home the next day. During the PTCA, patients receive large amounts of heparin and are monitored closely for signs of bleeding. Most patients also receive intravenous nitroglycerin for a period after the procedure to prevent arterial spasm. Hemostasis is usually achieved and sheaths are pulled immediately at the end of the procedure by using a vascular closure device (eg, Angio-Seal, VasoSeal, Duett, Syvek patch) or a device that sutures the vessels (Prostar, Perclose). Hemostasis after sheath removal may also be achieved by direct manual pressure, a mechanical compression device (eg, C-shaped clamp), or a pneumatic compression device (eg, FemStop). The patient may return to the nursing unit with the large peripheral vascular access sheaths in place. The sheaths are removed
Table 28-7
Management of Patients With Coronary Vascular Disorders
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after blood studies (eg, activated clotting time) indicate that the clotting time is within an acceptable range. This usually takes a few hours, depending on the amount of heparin given during the procedure. The patient must remain flat in bed and keep the affected leg straight until the sheaths are removed and then for a few hours after to maintain hemostasis. Because the immobility and bed rest usually cause the patient significant discomfort, treatment includes analgesics and sedation. Several nursing interventions frequently used as part of the standard of care, such as applying a sandbag to the sheath insertion site, have not been shown to be effective in reducing the incidence of bleeding (Christensen et al., 1998; Juran et al., 1999). The method used to achieve hemostasis determines the length of time needed to achieve hemostasis, the duration of bed rest, and the risk of complications (Brachmann et al., 1998; Lehmann et al., 1999; Walker et al., 2001). Sheath removal and the application of pressure on the vessel insertion site may cause the heart rate to slow and the blood pressure to decrease (vasovagal response). An intravenous bolus of atropine is usually used to treat these side effects. Some patients with unstable lesions and at high risk for abrupt vessel closure are restarted on heparin after sheath removal, or they receive an intravenous infusion of a GPIIb/IIIa inhibitor. These patients are monitored more closely and progressed more slowly. After hemostasis is achieved, patients usually can be weaned from the intravenous medications, resume self-care, and ambulate unassisted within 1 to 12 hours of the procedure. The duration of immobilization depends on the size of the sheath inserted, the amount of anticoagulant administered, the method of hemostasis, the patient’s underlying condition, and the physician’s preference. The nurse teaches the patient to monitor the site for bleeding or development of a hard lump that is larger than a walnut. Most patients can return to their usual activities of daily living.
• Complications After Percutaneous Transluminal Coronary Angioplasty (PTCA)
COMPLICATION
SIGNS AND SYMPTOMS
POSSIBLE CAUSES
NURSING ACTIONS
Bleeding or hematoma
Hard lump or bluish tinge at sheath insertion site
Coughing, vomiting, bending leg or hip, obesity, bladder distention, high blood pressure
Lost or weakened pulse distal to sheath insertion site
Extremity cool, cyanotic, pale, or painful
Arterial thrombus or embolus
Pseudoaneurysm and arteriovenous fistula
Pulsatile mass felt or bruit heard near sheath insertion site Back or flank pain Low blood pressure Tachycardia Restlessness and agitation Decreased hemoglobin Decreased hematocrit
Vessel trauma during procedure
Keep the head of the bed flat. Insert indwelling urinary catheter if needed Apply manual pressure at site of sheath insertion. Outline extent of hematoma with a marking pen. If bleeding does not stop, notify physician or nurse practitioner. Notify physician or nurse practitioner. Anticipate surgery and anticoagulation or thrombolytic therapy. Notify physician or nurse practitioner. Anticipate ultrasound-guided compression. Prepare patient for surgery to close fistula. Notify physician or nurse practitioner immediately. Stop any anticoagulation medication. Anticipate need for intravenous fluids and/or administration of blood.
Retroperitoneal bleeding
Arterial tear causing bleeding into flank area
Courtesy of Washington Adventist Hospital. Care of the interventional cardiology patient nursing protocol, based on communication from Amy Dukovic, Cardiac Interventional Nurse Practitioner.
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Coronary Artery Stent After PTCA, a portion of the plaque that was not removed may block the artery. The coronary artery may recoil (constrict) and the tissue remodels, increasing the risk for restenosis (Apple & Lindsay, 2000). A coronary artery stent is placed to overcome these risks. A stent is a woven mesh that provides structural support to a vessel at risk of acute closure. The stent is placed over the angioplasty balloon. When the balloon is inflated, the mesh expands and presses against the vessel wall, holding the artery open. The balloon is withdrawn, but the stent is left permanently in place within the artery (Fig. 286). Eventually, endothelium covers the stent and it is incorporated into the vessel wall. Because of the risk of thrombus formation in the stent, the patient receives antiplatelet medications (eg, clopidogrel [Plavix] therapy for 2 weeks and lifetime use of aspirin). Some stents have medication which may minimize the formation of thrombi or excessive scar tissue. It is estimated that 50% to 80% of all PCIs involve implanting at least one stent (Braunwald et al., 2001; Smith et al., 2001). Stents may be used in conjunction with PTCA or independently as a PCI. Use of stents without PTCA may decrease procedure time, use of the potentially nephrotoxic contrast agent, radiation exposure, and cost (Apple & Lindsay, 2000). Care of the patient after coronary artery stent placement is the same as for a patient after PTCA.
Atherectomy Atherectomy is an invasive interventional procedure that involves the removal of the atheroma, or plaque, from a coronary artery (Smith et al., 2001). Directional (DCA) and transluminal extraction (TEC) coronary atherectomy procedures involve the use of a catheter that removes the lesion and its fragments. Rotational atherectomy uses a catheter with diamond chips impregnated on the tip (called a burr) that rotates like a dentist’s drill at 130,000 to 180,000 rpm, pulverizing the lesion (Braunwald et al., 2001). Usually, several passes of these catheters are needed to achieve satisfactory results. Postprocedural patient care is the same as for a patient after PTCA.
Brachytherapy PTCA and stent implantation cause a cellular reaction in the coronary artery that promotes proliferation of the intima of the
A
artery, which also increases the possibility of arterial obstruction. Brachytherapy reduces the recurrence of obstruction, preventing vessel restenosis by inhibiting smooth muscle cell proliferation (Leon et al., 2001). Brachytherapy (from the Greek word, brachys, meaning short) involves the delivery of gamma or beta radiation by placing a radioisotope close to the lesion (Teirstein & Kuntz, 2001). The radioisotope may be delivered by a catheter or implanted with the stent. Long-term studies are needed to identify if the beneficial effects of radiation therapy are sustained and to determine the optimal dose and type of isotope to use for brachytherapy.
Transmyocardial Revascularization Patients who have cardiac ischemia and who are not candidates for CABG may benefit from transmyocardial laser revascularization (TMR) (Burkhoff et al., 1999). The procedure may be performed percutaneously in the cardiac catheterization laboratory (percutaneous transmyocardial revascularization [PTMR]) or through a midsternal or thoracotomy incision in the operating room (Acorda et al., 2000). The tip of a fiberoptic catheter is held firmly against the ischemic area of the heart while a laser burns a channel into but not through the muscle. If the procedure is percutaneous, the catheter is positioned inside the ventricle. If the procedure is surgical, the catheter is positioned on the outer surface of the ventricle. Each procedure usually involves making 20 to 40 channels. It is thought that some blood flows into the channels, decreasing the ischemia directly. Within the next few days to months, the channels close as a result of the body’s inflammatory process of healing a wound (Platek & Atzori, 1999). The long-term result is the formation of new blood vessels (angiogenesis) during the inflammatory process that follows the laser burns (Anderson, 2000; Braunwald et al., 2001; Fuster et al., 2001; Hayden, 1998; Platek, & Atzori, 1999). The new blood vessels provide enough blood to decrease the symptoms of cardiac ischemia. Nursing care before, during, and after the procedure depends on the approach: if the approach was percutaneous, the patient care is the same as following a PTCA; if the approach was surgical, the patient care is the same as following CABG.
Deflated balloon
Closed stent
Plaque Catheter Inflated balloon
B
C
Plaque
Open stent
Open stent
FIGURE 28-6 Intracoronary artery stent. (A) Stent closed, before balloon inflation. (B) Stent open, balloon inflated; stent will remain expanded after balloon is deflated and removed. (C) Stent open, balloon removed.
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SURGICAL PROCEDURES Coronary Artery Revascularization Advances in diagnostics, medical management, surgical and anesthesia techniques, and cardiopulmonary bypass (CPB), as well as the care provided in critical care and surgical units, home care, and rehabilitation programs, have helped make surgery a viable treatment option for patients with cardiac disease. CAD has been treated by some form of myocardial revascularization since the 1960s; the most common CABG techniques have been performed for approximately 35 years. CABG is a surgical procedure in which a blood vessel from another part of the body is grafted to the occluded coronary artery so that blood can flow beyond the occlusion; it is also called a bypass graft. Candidates for CABG are usually patients with the following conditions (Eagle et al., 1999):
Great saphenous vein
• Angina that cannot be controlled by medical therapies • Unstable angina • A positive exercise tolerance test and lesions or blockage that cannot be treated by PCI
• A left main coronary artery lesion or blockage of more than 60%
• Blockage of two or three coronary arteries, one of which is • •
the proximal left anterior descending artery Left ventricular dysfunction with blockages in two or more coronary arteries Complications from or unsuccessful PCIs
For a patient to be considered for CABG, the coronary arteries to be bypassed must have at least a 70% occlusion (60% if it is the left main coronary artery). If the lesion involves less than 70% of the artery, enough blood can flow through the blocked artery to prevent adequate blood flow through the bypass graft. As a result, the graft would clot, effectively negating the surgery. The vessel most commonly used for CABG is the greater saphenous vein, followed by the lesser saphenous vein (Fig. 28-7). Cephalic and basilic veins are used also. The vein is removed from the leg (or arm) and grafted to the ascending aorta and to the coronary artery distal to the lesion. The saphenous veins are used in emergency CABG procedures because they can be obtained by one surgical team while another team performs the chest surgery. One side effect of using a large vein is edema, which may develop in the extremity from which it was taken. The degree of edema varies and may diminish over time. Approximately 5 to 10 years after CABG, symptomatic atherosclerotic changes develop in saphenous veins used for grafting. In arm veins, the same changes develop more quickly, approximately 3 to 6 years after the surgery. The right and left internal mammary arteries and, occasionally, radial arteries are also used for CABG. Arterial grafts are preferred to vein grafts because they do not develop atherosclerotic changes as quickly and remain patent longer. In general, the surgeon leaves the proximal end of the mammary artery intact and detaches the distal end of the artery from the chest wall. This distal end of the artery is then grafted to the coronary artery distal to the occlusion. Disadvantages of using the internal mammary arteries are that they may not be long enough or wide enough for the bypass and ulnar nerve damage may result. The gastroepiploic artery (located along the greater curvature of the stomach) may also be used, although it does not respond as well when used as a graft. It has a more extensive blood supply to its wall than the internal mammary arteries, making dissection from the stomach difficult and increasing the potential for injury
Small saphenous vein
FIGURE 28-7 The greater and lesser saphenous veins are the vessels most commonly used in bypass graft procedures.
and ischemia of the graft. Use of the gastroepiploic artery requires the surgeon to extend the chest incision to the abdomen, thereby exposing the patient to the additional risks of an abdominal incision and infection at the surgical site from contamination by the gastrointestinal tract. TRADITIONAL CORONARY ARTERY BYPASS GRAFT The traditional CABG procedure is performed with the patient under general anesthesia. Usually, the surgeon makes a median sternotomy incision and connects the patient to the CPB machine. Next, a blood vessel from another part of the patient’s body (eg, saphenous vein, left internal mammary artery) is grafted distal to the coronary artery lesion, bypassing the obstruction (Fig. 28-8). CPB is then discontinued and the incision is closed. The patient then is admitted to a critical care unit. Cardiopulmonary Bypass (CPB). Many cardiac surgical procedures are possible because of CPB (ie, extracorporeal circulation). The procedure mechanically circulates and oxygenates blood for the body while bypassing the heart and lungs. CPB uses a heartlung machine to maintain perfusion to other body organs and tissues while the surgeon works in a bloodless surgical field. CPB, a common but complex technique, is accomplished by placing a cannula in the right atrium, vena cava, or femoral vein
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Left subclavian artery Internal mammary artery graft (A) Saphenous vein graft (B) Blockage Blockages Diaphragm
Stomach
Right gastroepiploic artery (C) Duodenum
FIGURE 28-8 Three coronary artery bypass grafts. One or more procedures may be performed using various veins and arteries. (A) Left internal mammary artery, popular because of its functional longevity. (B) Saphenous vein, the most frequently constructed bypass. (C) Right gastroepiploic artery, rarely used because this artery has a more extensive blood supply to its wall (increasing the risk of bleeding and necrosis of the artery) and because of the risk of gastrointestinal tract contamination of the abdominal or mediastinal wound.
to withdraw blood from the body. The cannula is connected to tubing filled with an isotonic crystalloid solution (usually 5% dextrose in lactated Ringer’s solution). Venous blood removed from the body by the cannula is filtered, oxygenated, cooled or warmed, and then returned to the body. The cannula used to return the oxygenated blood is usually inserted in the ascending aorta, but it may be inserted in the femoral artery (Fig. 28-9). The patient receives heparin, an anticoagulant, to prevent thrombus formation and possible embolization that may occur when blood contacts the foreign surfaces of the CPB circuit and is pumped into the body by a mechanical pump (not the normal blood vessels and heart). After the patient is disconnected from the bypass machine, protamine sulfate is administered to reverse the effects of heparin. During the procedure, hypothermia is maintained, usually 28°C to 32°C (82.4°F to 89.6°F). The blood is cooled during CPB and returned to the body. The cooled blood slows the body’s basal metabolic rate, thereby decreasing its demand for oxygen. Cooled blood usually has a higher viscosity, but the crystalloid solution used to prime the bypass tubing dilutes the blood. When the surgical procedure is completed, the blood is rewarmed as it passes through the CPB circuit. Urine output, blood pressure, arterial blood gas measurements, electrolytes, coagulation studies, and the ECG are monitored to assess the patient’s status during CPB. MINIMALLY INVASIVE DIRECT CABG (MIDCAB) For patients with single coronary artery blockages who cannot be treated by PTCA or with contraindications for CPB, an alternative to traditional CABG is minimally invasive direct CABG (MIDCAB). With the patient under general anesthesia, the surgeon makes one or more 2- to 4-inch (5- to 10-cm) incisions in
Ascending aorta
Superior vena cava
Aorta-cross-clamp
Heat exchanger Venous reservoir
Heart
Filter Inferior vena cava Pump Oxygenator Filter
Right atrium
FIGURE 28-9 The cardiopulmonary bypass system, in which cannulae are placed through the right atrium into the superior and inferior vena cavae to divert blood from the body and into the bypass system. The pump system creates a vacuum, pulling blood into the venous reservoir. The blood is cleared of air bubbles, clots, and particulates by the filter, and then is passed through the oxygenator, releasing carbon dioxide and obtaining oxygen. Next, the blood is pulled to the pump and pushed out to the heat exchanger, where its temperature is regulated. The blood is then returned to the body via the ascending aorta.
Chapter 28 the chest wall for a left or right anterior thoracotomy or for a midsternal or midline upper laparotomy. The graft is prepared for the bypass (see previous graft selection description). The surgeon identifies the location of the coronary artery for the CAB, and a special instrument, a myocardial stabilizer, is put around the site. The stabilizer holds the graft site still for the surgeon while the heart continues to beat. Other techniques to minimize movement of the beating heart are to temporarily collapse the lung on the side of the chest where the surgery is being performed, decrease the respiratory rate and the volume of each breath, and give medications to cause bradycardia or up to 20 seconds of asystole. Patients treated with MIDCAB may recover from anesthesia in the postanesthesia care unit (PACU) and then be admitted to a telemetry unit for 1 to 3 days. Nursing care is often directed toward routine postoperative pulmonary interventions (especially if a lung was collapsed during the MIDCAB) and incisional pain management (especially if a thoracotomy incision was made). PORT ACCESS CORONARY ARTERY BYPASS GRAFT Port access CABG is another alternative to traditional CABG. With the patient under general anesthesia, the surgeon makes three or more incisions (ports) to perform the CABG. One 0.5to 1-inch (1.3- to 2.5-cm) incision in the groin provides access to a femoral artery and vein. The femoral artery is used for a multipurpose catheter threaded retrograde through the aorta to the ascending aorta. The catheter is used to return blood from CPB to the patient, to occlude the aorta by inflating a balloon near the end of the catheter, to provide a cardioplegia solution to the coronary arteries, and to vent air from the aortic root during the surgical procedure. The femoral vein is used for a catheter threaded through the vena cava to the right atrium to drain blood from the patient for CPB. Another 0.5- to 1-inch (1.3- to 2.5-cm) incision in the neck provides access to the jugular vein for two catheters. One catheter is threaded into the pulmonary artery to remove air, fluid, and blood that may enter the right heart during surgery. The other catheter is threaded into the right atrium and the tip positioned in the coronary sinus for retrograde infusion of the cardioplegia solution. One or more thoracotomy incisions, usually 2 to 3.5 inches (5 to 9 cm) long, are made for insertion of the surgical instruments. One of the thoracotomy ports may be used for video-assisted imaging equipment. CPB is begun when the equipment is in place through the groin, neck, and thoracotomy incisions. The balloon on the aortic catheter is inflated, and the cardioplegia solution is injected into the coronary arteries. Cardioplegia solution is a crystalloid and electrolyte liquid used to stop the heart and protect the myocardium during cardiac surgical procedures. One lung may be temporarily collapsed to assist with exposing the surgical site. The CABG is performed through a thoracotomy incision. When the CABG is complete, air is vented from the pulmonary artery and aorta. The balloon on the aortic catheter is deflated, and CPB is discontinued. The surgical instruments and the catheters are removed. The incisions are closed. The patient’s postoperative care is similar to that after traditional CABG. COMBINATION PERCUTANEOUS TRANSLUMINAL CORONARY ANGIOPLASTY AND CORONARY ARTERY BYPASS GRAFT Patients who have blockages in the left anterior descending and at least one other coronary artery who are not candidates for traditional CABG or prefer less invasive procedures may be treated with both MIDCAB and PTCA. Because patients need their blood to
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be able to clot after MIDCAB, but require anticoagulation after PTCA, the sequence and timing of providing both treatments to the same patient are being investigated. COMPLICATIONS CABG may result in complications such as MI, dysrhythmias, and hemorrhage (see Table 28-2; these complications are discussed in depth in this chapter, in Chapter 27, and in Chapters 20 and 71). The patient’s underlying heart disease remains, and angina, exercise intolerance, or other symptoms experienced before CABG may develop again. Medications required before surgery may need to be continued. Lifestyle modifications recommended before surgery remain important to treat the underlying CAD and for the continued viability of the newly implanted grafts (see Plan of Nursing Care, pp. 740–745).
NURSING PROCESS: THE PATIENT AWAITING CARDIAC SURGERY The cardiac surgery patient has many of the same needs and requires the same perioperative care as other surgical patients (see Chaps. 18 through 20). The patient and family are experiencing a major life crisis. The association of the heart with life and death intensifies their emotional and psychological needs. Patients frequently are admitted the same day as the procedure. For these patients, the nurse must prioritize needs carefully; in the time allowed, the nurse focuses on the needs that have the highest priority. Before surgery, physical and psychological assessments establish the baselines for future reference. The patient’s understanding of the surgical procedure, informed consent, and adherence to treatment protocols are evaluated. Helping the patient to cope, understand the procedure, and maintain dignity are nursing responsibilities. The preoperative phase of cardiac surgery begins before hospitalization. The nurse assesses the patient for other disorders, such as diabetes, hypertension, and respiratory, gastrointestinal, and hematologic diseases, and documents their treatment. The nurse clarifies how the medication regimen is to be altered before surgery, such as tapering corticosteroids and digoxin, decreasing or discontinuing anticoagulants, and maintaining medications for treatment of blood pressure, angina, diabetes, and dysrhythmias. The nurse also clarifies the need to maintain activity patterns, a healthy diet, healthful sleep habits, and cessation of smoking to minimize the risks of surgery.
Assessment Patients with nonacute heart disease may be admitted to the hospital the day of or the day before the surgery. Most of the preoperative evaluation is completed before the patient enters the hospital. Many surgeons’ offices or hospitals mail an information packet to the patient’s home. A history and physical examination are performed by nursing and medical personnel. A chest x-ray, ECG, laboratory tests, blood typing and crossmatching, and autologous blood donation (patient’s own blood) may also be performed. The health assessment focuses on obtaining baseline physiologic, psychological, and social information. The patient’s and family’s learning needs are identified and addressed as necessary. Of particular importance are the patient’s usual functional level, coping mechanisms, and support systems. These are important because the support of the family or (text continues on page 745)
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Plan of Nursing Care Care of the Patient After Cardiac Surgery Nursing Interventions
Rationale
Expected Outcomes
Nursing Diagnosis: Decreased cardiac output related to blood loss and compromised myocardial function Goal: Restoration of cardiac output to maintain/attain desired lifestyle 1. Monitor cardiovascular status. Serial readings of blood pressures (arterial, left atrial, pulmonary artery, pulmonary artery wedge pressure [PAWP], central venous pressure [CVP]), cardiac output/index, systemic and pulmonary vascular resistance, and cardiac rhythm and rate are obtained, recorded, and correlated with the patient’s condition. a. Assess arterial blood pressure every 15 minutes until stable; then arterial or cuff blood pressure every 1–4 hours × 24 hours; then every 8–12 hours until hospital discharge; then every visit. b. Auscultate for heart sounds and rhythm.
c. Assess peripheral pulses (pedal, tibial, radial, carotid). d. Measure left atrial pressure, pulmonary artery diastolic (PAD) pressure, and PAWP to determine left ventricular end-diastolic volume and to assess cardiac output. e. Monitor PAWP, PAD, left atrial pressure, and CVP to assess blood volume, vascular tone, and pumping effectiveness of the heart. Remember: Trends are more important than isolated readings. Mechanical ventilation may elevate CVP. f. Monitor ECG pattern for cardiac dysrhythmias (see Chap. 27 for discussion of dysrhythmias).
g. Assess cardiac enzyme test results when available. h. Measure urine output every 1⁄2 hour to 1 hour at first, then with vital signs. i. Observe buccal mucosa, nailbeds, lips, earlobes, and extremities. j. Assess skin; note temperature and color.
1. Effectiveness of cardiac output is determined by hemodynamic monitoring.
a. Blood pressure is one of the most important physiologic parameters to follow; vasoconstriction after cardiopulmonary bypass may make auscultatory blood pressure unobtainable. b. Auscultation provides evidence of cardiac tamponade (muffled distant heart sounds), pericarditis (precordial rub), dysrhythmias. c. Presence or absence and quality of pulses provide data about cardiac output as well as obstructive lesions. d. Rising pressures may indicate congestive heart failure or pulmonary edema.
The following parameters are within the patient’s normal ranges: • Arterial pressure • Left atrial pressures • PAWP • Pulmonary artery pressures • CVP • Heart sounds • Pulmonary and systemic vascular resistance • Cardiac output and cardiac index • Peripheral pulses • Cardiac rate and rhythm • Cardiac enzymes • Urine output • Skin and mucosal color • Skin temperature
e. High PAWP, PAD, left atrial pressure, or CVP may result from hypervolemia, heart failure, cardiac tamponade. If blood pressure drop is due to low blood volume, PAWP, PAD, left atrial pressure, and CVP will show corresponding drop. f. Dysrhythmias may occur with coronary ischemia, hypoxia, alterations in serum potassium, edema, bleeding, acid-base or electrolyte disturbances, digitalis toxicity, cardiac failure. STsegment changes may indicate myocardial ischemia or coronary artery spasm. Pacemaker capture and antiarrhythmic medication effects are used to maintain a heart rate and rhythm to support stable blood pressures. g. Elevations may indicate myocardial infarction. h. Urine output less than 25 mL/h indicates decreased renal perfusion and may reflect decreased cardiac output. i. Duskiness and cyanosis may indicate decreased cardiac output. j. Cool moist skin indicates vasoconstriction and decreased cardiac output.
(continued)
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Plan of Nursing Care Care of the Patient After Cardiac Surgery (Continued) Nursing Interventions
Rationale
Expected Outcomes
2. Observe for persistent bleeding: steady, continuous drainage of blood; hypotension; low CVP; tachycardia. Prepare to administer blood products, IV solutions. 3. Observe for cardiac tamponade: hypotension; rising PAWP, PAD, left atrial pressure, or CVP; muffled heart sounds; weak, thready pulse; jugular vein distention; decreasing urinary output. Check for diminished amount of blood in chest drainage collection system. Prepare for pericardiocentesis. Assess for pulsus paradoxus. 4. Observe for cardiac failure: hypotension, rising PAWP, PAD, CVP, and left atrial pressure, tachycardia, restlessness, agitation, cyanosis, venous distention, dyspnea, moist crackles, ascites. Prepare to administer diuretics and digoxin. 5. Observe for myocardial infarction: ST-segment elevations, T-wave changes, decreased cardiac output in the presence of normal circulating volume and filling pressures. Obtain serial ECGs and isoenzymes. Differentiate myocardial pain from incisional pain.
2. Bleeding can result from cardiac incision, tissue fragility, trauma to tissues, clotting defects.
• Less than 200 mL/hr of drainage through
3. Cardiac tamponade results from bleeding into the pericardial sac or accumulation of fluid in the sac, which compresses the heart and prevents adequate filling of the ventricles. Decrease in chest drainage may indicate fluid is accumulating in the pericardial sac.
chest tubes during first 4 to 6 hours
• Vital signs stable • Chest tube drainage expected amount • CVP and left atrial pressures within normal • • • • •
limits Urinary output within normal limits Skin color normal Respirations unlabored, clear breath sounds Pain limited to incision ECG and isoenzymes negative for ischemic changes
4. Cardiac failure results from decreased pumping action of the heart; can cause deficient blood perfusion to vital organs.
5. Symptoms may be masked by the patient’s level of consciousness and pain medication.
Nursing Diagnosis: Impaired gas exchange related to trauma of extensive chest surgery Goal: Adequate gas exchange 1. Maintain mechanical ventilation until the patient is able to breathe independently. 2. Monitor arterial blood gases, tidal volumes, peak inspiratory pressures, and extubation parameters. 3. Auscultate chest for breath sounds. 4. Sedate patient adequately, as prescribed, and monitor respiratory rate and depth if ventilations are not “controlled.” 5. Promote deep breathing, forced expiratory technique (FET, coughing), and turning. Encourage use of the incentive spirometer and compliance with breathing treatments. Teach incisional splinting with a “cough pillow” to decrease discomfort during deep breathing and FET (coughing). 6. Suction tracheobronchial secretions as needed, using strict aseptic technique. 7. Assist in weaning and endotracheal tube removal.
1. Ventilatory support may be used to decrease work of the heart, to maintain effective ventilation, and to provide an airway in the event of cardiac arrest. 2. ABGs and tidal volume indicate effectiveness of ventilator and changes that need to be made to improve gas exchange. 3. Crackles indicate pulmonary congestion; decreased or absent breath sounds may indicate pneumothorax or hemothorax. 4. Sedation helps the patient to tolerate the endotracheal tube and to cope with ventilatory sensations; sedatives can depress respiratory rate and depth. 5. Aids in keeping airway patent, preventing atelectasis, and facilitating lung expansion.
• Airway patent • ABGs within normal range • Endotracheal tube correctly placed, as evi• • • • • •
denced by x-ray Breath sounds clear Ventilator synchronous with respirations Breath sounds clear after suctioning/FET Nailbeds and mucous membranes pink Mental acuity consistent with amount of sedatives and analgesics received Oriented to person; able to respond yes and no appropriately
6. Retention of secretions leads to hypoxia and possible cardiac arrest; retained secretions promote infection. 7. Decreased risk of pulmonary infections and enhanced ability of patient to communicate without an endotracheal tube. (continued)
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Plan of Nursing Care Care of the Patient After Cardiac Surgery (Continued) Nursing Interventions
Rationale
Expected Outcomes
Nursing Diagnosis: Risk for deficient fluid volume and electrolyte imbalance related to alterations in blood volume Goal: Fluid and electrolyte balance 1. Maintain fluid and electrolyte balance.
a. Keep intake and output flow sheets; record urine volume every 1 ⁄ 2 hour to 4 hours while in critical care unit; then every 8 to 12 hours while hospitalized. b. Assess the following parameters: pulmonary artery pressures, left atrial pressures, blood pressure, CVP, PAWP, weight, electrolyte levels, hematocrit, jugular venous pressure, tissue turgor, liver size, breath sounds, urinary output, and nasogastric tube drainage. c. Measure postoperative chest drainage (should not exceed 200 mL/hr for first 4 to 6 hours); cessation of drainage may indicate kinked or blocked chest tube. Ensure patency and integrity of the drainage system. Maintain autotransfusion system if in use. d. Weigh daily once patient is ambulatory. 2. Be alert to changes in serum electrolyte levels. a. Hypokalemia (low potassium) Effects: dysrhythmias, digitalis toxicity, metabolic alkalosis, weakened myocardium, cardiac arrest Observe for specific ECG changes. Administer IV potassium replacement as directed. b. Hyperkalemia (high potassium) Effects: mental confusion, restlessness, nausea, weakness, paresthesias of extremities Be prepared to administer an ionexchange resin (sodium polystyrene sulfonate [Kayexalate]); IV sodium bicarbonate, or IV insulin and glucose.
c. Hypomagnesemia (low magnesium) Effects: paresthesias, carpopedal spasm, muscle cramps, tetany, irritability, tremors, hyperexcitability, hyperreflexia, disorientation, depression, seizures, hypotension, dysrhythmias, prolonged PR and QT intervals, broad flat T waves.
1. Adequate circulating blood volume is necessary for optimal cellular activity; metabolic acidosis and electrolyte imbalance can occur after use of cardiopulmonary bypass. a. Provides a method to determine positive or negative fluid balance and fluid requirements.
• Fluid intake and output balanced • Hemodynamic assessment parameters negative for fluid overload and dehydration
• Normal blood pressure with position changes
• Absence of dysrhythmia • Stable weight • Notify physician if weight gain of 2 lb or more in 1 day or 5 lb or more in 1 week.
b. Provides information about state of hydration.
• Blood pH 7.35 to 7.45 • Serum potassium 3.5 to 5.0 mEq/L (3.5 to 5.0 mmol/L)
• Serum magnesium 1.5 to 2.5 mEq/L (0.75 to 1.25 mmol/L)
• Serum sodium 135 to 145 mEq/L (135 to 145 mmol/L)
c. Excessive blood loss from chest cavity can cause hypovolemia.
• Serum calcium 8.8 to 10.3 mg/100 mL (2.20 to 2.58 mmol/L)
d. Indicator of fluid balance. 2. A specific concentration of electrolytes is necessary in both extracellular and intracellular body fluids to sustain life. a. Causes: inadequate intake, diuretics, vomiting, excessive nasogastric drainage, stress from surgery
b. Causes: increased intake, hemolysis from cardiopulmonary bypass/mechanical assist devices, acidosis, renal insufficiency, tissue necrosis, adrenal cortical insufficiency. The resin binds potassium and promotes intestinal excretion of it. IV sodium bicarbonate drives potassium into the cells from extracellular fluid. Insulin assists the cells with glucose absorption. The glucose provides the energy to activate the sodium–potassium pumps, which pull potassium into the cell while pumping sodium out. c. Causes: decreased intake (chronic alcoholism, malnutrition, starvation), impaired absorption (malabsorption syndromes, excess intake of calcium) and increased excretion normal for 24 hours after major surgery, diuretic loss of intestinal fluids, diabetic ketoacidosis, primary aldosteronism, primary hyperparathyroidism.
(continued)
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Plan of Nursing Care Care of the Patient After Cardiac Surgery (Continued) Nursing Interventions Be prepared to treat the cause. Magnesium supplements may be given (oral route preferred, extreme caution if IV). d. Hypermagnesemia (high magnesium) Effects: vasodilation, flushing, warm feeling, hypotension, loss of reflexes, slowing bowel function, drowsiness, respiratory depression, coma, apnea, cardiac arrest. Be prepared to treat cause; dialysis and calcium gluconate administration. e. Hyponatremia (low sodium) Effects: weakness, fatigue, confusion, seizures, coma Administer sodium or diuretics as prescribed. f. Hypocalcemia (low calcium) Effects: numbness and tingling in fingertips, toes, ears, nose; carpopedal spasm; muscle cramps; tetany Administer replacement therapy as prescribed. g. Hypercalcemia (high calcium) Effects: dysrhythmias, digitalis toxicity, asystole Institute treatment as prescribed.
Rationale
Expected Outcomes
d. Causes: renal failure, excess intake of medications with magnesium (antacids, cathartics)
e. Causes: reduction of total body sodium, or increased water intake causing dilution of sodium f. Causes: alkalosis, multiple blood transfusions of citrated blood products
g. Cause: prolonged immobility
Nursing Diagnosis: Disturbed sensory perception related to excessive environmental stimulation, sleep deprivation, electrolyte imbalance Goal: Reduction of symptoms of sensory perceptual imbalance; prevention of postcardiotomy psychosis 1. Use measures to prevent postcardiotomy psychosis: a. Explain all procedures and the need for patient cooperation. b. Plan nursing care to provide for periods of uninterrupted sleep with patient’s normal day–night pattern. c. Decrease sleep-preventing environmental stimuli as much as possible. d. Promote continuity of care from nurse to nurse. e. Orient to time and place frequently. Encourage family to visit at regular times. f. Assess for medications that may contribute to delirium. g. Teach relaxation techniques and diversions. h. Encourage self-care as much as tolerated to enhance self-control. Assess support systems and coping mechanisms 2. Observe for perceptual distortions, hallucinations, disorientation, and paranoid delusions.
1. Postcardiotomy psychosis may result from anxiety, sleep deprivation, increased sensory input, disorientation to night and day. Normally, sleep cycles are at least 50 min long. The first cycle may be as long as 90 to 120 min and then shorten during successive cycles. Sleep deprivation results when the sleep cycles are interrupted or there are not enough of them.
• • • •
Cooperates with procedures Sleeps for long, uninterrupted intervals Oriented to person, place, time Experiences no perceptual distortions, hallucinations, disorientation, delusions
(continued)
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CARDIOVASCULAR, CIRCULATORY, AND HEMATOLOGIC FUNCTION
Plan of Nursing Care Care of the Patient After Cardiac Surgery (Continued) Nursing Interventions
Rationale
Expected Outcomes
Nursing Diagnosis: Acute pain related to surgical trauma and pleural irritation caused by chest tubes and/or internal mammary artery dissection Goal: Relief of pain 1. Record nature, type, location, intensity, and duration of pain. 2. Assist patient to differentiate between surgical pain and anginal pain. 3. Encourage routine pain medication dosing for the first 24 to 72 hours and observe for side effects of lethargy, hypotension, tachycardia, respiratory depression.
1. Pain and anxiety increase pulse rate, oxygen consumption, and cardiac workload. 2. Anginal pain requires immediate treatment. 3. Analgesia promotes rest, decreases oxygen consumption caused by pain, and aids patient in performing deep-breathing and FET (coughing) exercises; pain medications is more effective when taken before pain is severe.
• • • • • • • •
States pain is decreasing in severity Reports absence of pain Restlessness decreased Vital signs stable Participates in deep-breathing and forced expiratory technique (FET, coughing) exercises Verbalizes fewer complaints of pain each day Positions self; participates in care activities Gradually increases activity
Nursing Diagnosis: Ineffective renal tissue perfusion related to decreased cardiac output, hemolysis, or vasopressor drug therapy Goal: Maintenance of adequate renal perfusion 1. Assess renal function:
a. Measure urine output every 1⁄2 hour to 4 hours in critical care then every 8–12 hours until hospital discharge. b. Measure urine specific gravity. c. Monitor and report lab results: BUN, serum creatinine, urine and serum electrolytes. 2. Prepare to administer rapid-acting diuretics or inotropic drugs (eg, dopamine, dobutamine). 3. Prepare patient for dialysis or continuous renal replacement therapy if indicated.
1. Renal injury can be caused by deficient perfusion, hemolysis, low cardiac output, and use of vasopressor agents to increase blood pressure. a. Less than 25 mL/h indicates decreased renal function.
• Urine output consistent with fluid intake; greater than 25 mL/hr
• Urine specific gravity 1.015 to 1.025 • BUN, creatinine, electrolytes within normal limits
b. Indicates kidneys’ ability to concentrate urine in renal tubules. c. Indicate kidneys’ ability to excrete waste products. 2. Promote renal function and increase cardiac output and renal blood flow. 3. Patients have the right to know what care is prescribed; provides patient with the opportunity to ask questions and prepare for the procedure.
Nursing Diagnosis: Ineffective thermoregulation related to infection or postpericardiotomy syndrome Goal: Maintenance of normal body temperature 1. Assess temperature every hour. 2. Use aseptic technique when changing dressings, suctioning endotracheal tube; maintain closed systems for all intravenous and arterial lines and for indwelling urinary catheter. 3. Observe for symptoms of postpericardiotomy syndrome: fever, malaise, pericardial effusion, pericardial friction rub, arthralgia. 4. Administer anti-inflammatory agents as directed.
1. Fever can indicate infectious process or postpericardiotomy syndrome. 2. Decreases risk of infection.
• Normal body temperature • Incisions are free of infection and are healing
• Absence of symptoms of postpericardiotomy syndrome
3. Occurs in 10% to 40% of patients after cardiac surgery. 4. Relieve symptoms of inflammation (eg, warm or flushed sensation, swelling, fullness, stiffness or aching sensation, and fatigue). (continued)
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Plan of Nursing Care Care of the Patient After Cardiac Surgery (Continued) Nursing Interventions
Rationale
Expected Outcomes
Nursing Diagnosis: Deficient knowledge about self-care activities Goal: Ability to perform self-care activities 1. Develop teaching plan for patient and family. Provide specific instructions for the following: • Diet and daily weights • Activity progression • Exercise • Deep breathing, FET (coughing), lung expansion exercises • Temperature monitoring • Medication regimen • Pulse taking • CPR, if appropriate for the family to learn • Entry to the emergency medical system • Need for MedicAlert identification 2. Provide verbal and written instructions; provide several teaching sessions for reinforcement and answering questions.
3. Involve family in all teaching sessions. 4. Provide information regarding follow-up phone call to surgeon, cardiologist, or liaison nurse; follow-up visit with surgeon. 5. Make appropriate referrals: home care agency, cardiac rehabilitation program, community support groups, Mended Hearts Club.
1. Each patient will have unique learning needs.
• Patient and family members explain and comply with all therapeutic regimen
• Patient and family members identify • • •
lifestyle changes necessitated by therapeutic regimen Has copy of discharge instructions (in the patient’s primary language) Makes follow-up phone calls Keeps follow-up appointments
2. Repetition promotes learning by allowing for clarification of misinformation. After cardiac surgery, patients have short-term memory difficulty; information written in the patient’s primary language is essential because it can be used as a resource after discharge. The less familiar or greater the amount of the content the patient and family need to learn, the more time it will take to learn. 3. Family member responsible for home care is usually anxious and requires adequate time for learning. 4. Arrangements for phone contacts with health care personnel help to allay anxieties. 5. Learning and lifestyle changes continue after discharge from the hospital.
significant others will affect the patient’s postoperative course and rehabilitation. Discharge plans are influenced by the lifestyle demands of the home situation and the physical environment of the home. HEALTH HISTORY The preoperative history and health assessment should be thorough and well documented because they provide a basis for postoperative comparison. A systematic assessment of all systems is performed, with emphasis on cardiovascular functioning. Functional status of the cardiovascular system is determined by reviewing the patient’s symptoms, including past and present experiences with chest pain, hypertension, palpitations, cyanosis, breathing difficulty (dyspnea), leg pain that occurs with walking (intermittent claudication), orthopnea, paroxysmal nocturnal dyspnea, and peripheral edema. Because alterations in cardiac output can affect renal, respiratory, gastrointestinal, integumentary, hematologic, and neurologic functioning, a history of
these systems is also reviewed. The patient’s history of major illnesses, previous surgeries, medication therapies, and use of drugs, alcohol, and tobacco is also obtained. PHYSICAL ASSESSMENT A complete physical examination is performed, with special emphasis on the following:
• • • • • • • •
General appearance and behavior Vital signs Nutritional and fluid status, weight, and height Inspection and palpation of the heart, noting the point of maximal impulse, abnormal pulsations, and thrills Auscultation of the heart, noting pulse rate, rhythm, and quality; S3 and S4, snaps, clicks, murmurs, and friction rub Jugular venous pressure Peripheral pulses Peripheral edema
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PSYCHOSOCIAL ASSESSMENT The psychosocial assessment and the assessment of the patient’s and family’s learning needs are as important as the physical examination. Anticipation of cardiac surgery is a source of great stress to the patient and family. They will be anxious and fearful and often have many unanswered questions. Their anxiety usually increases with the patient’s admission to the hospital and the immediacy of surgery. An assessment of the level of anxiety is important. If it is low, it may indicate denial. If it is extremely high, it may interfere with the use of effective coping mechanisms and with preoperative teaching. Questions may be asked to obtain the following information:
• • • • • • •
Meaning of the surgery to the patient and family Coping mechanisms that are being used Measures used in the past to deal with stress Anticipated changes in lifestyle Support systems in effect Fears regarding the present and the future Knowledge and understanding of the surgical procedure, postoperative course, and long-term rehabilitation
The nurse allows adequate time for the patient and family to express their fears. The fears most often expressed are fear of the unknown, fear of pain, fear of body image change, and fear of dying. During the assessment, the nurse determines how much the patient and family know about the impending surgery and the expected postoperative events. They are encouraged to ask questions and to indicate how much information they wish to receive. Some patients prefer not to have detailed information, whereas others want to know as much as possible. Patients are approached as unique individuals with their own specific learning needs, learning styles, and levels of understanding. Patients requiring emergency heart surgery may have cardiac catheterization and surgery within several hours of admission. The nurse will have little opportunity to assess and meet their emotional and learning needs before surgery. As a result, patients will need extra help after surgery to adjust to the situation.
Diagnosis NURSING DIAGNOSES The nursing diagnoses for patients awaiting cardiac surgery vary according to each patient’s cardiac disease and symptoms. Most patients have a nursing diagnosis of decreased cardiac output (see Cardiac Failure in Chap. 30). Preoperative nursing diagnoses for most patients may include:
• Fear related to the surgical procedure, its uncertain outcome, and the threat to well-being
• Deficient knowledge regarding the surgical procedure and the postoperative course
COLLABORATIVE PROBLEMS/POTENTIAL COMPLICATIONS The stress of impending cardiac surgery may precipitate complications that require collaborative management with the physician. Based on the assessment data, potential complications that may develop include:
• Angina or anginal pain equivalent • Severe anxiety requiring an anxiolytic (anxiety-reducing) medication
• Cardiac arrest
Planning and Goals The major goals of the patient may include reducing fear, learning about the surgical procedure and postoperative course, and avoiding complications.
Nursing Interventions During the preoperative phase of cardiac surgery, the nurse develops a plan of care that includes emotional support and teaching for the patient and family. Establishing rapport, answering questions, listening to fears and concerns, clarifying misconceptions, and providing information about what to expect are interventions the nurse uses to prepare the patient and family emotionally for the surgery and for the postoperative events. REDUCING FEAR The patient and family are provided time and opportunities to express their fears. If there is fear of the unknown, other surgical experiences that the patient has had can be compared with the impending surgery. It is often helpful to describe to the patient the sensations that are expected. If the patient has already had a cardiac catheterization, the similarities and differences between that procedure and the surgery may be compared. The patient is encouraged to talk about any concerns related to previous experiences. A discussion of the patient’s fears about pain is initiated. A comparison is made between the pain experienced with cardiac surgery and other pain experiences. The preoperative sedation, the anesthetic, and the postoperative pain medications are described. The nurse reassures the patient that the fear of pain is normal, that some pain will be experienced, that medication to relieve pain will be provided, and that the patient will be closely observed. The patient is encouraged to take pain medication before the pain becomes severe. Positioning and relaxation will make the pain more tolerable. Patients who have a fear of scarring from surgery are encouraged to discuss this concern, and misconceptions are corrected. It may be helpful to indicate that the health care team members will keep the patient informed about the healing process. The patient and family are encouraged to talk about their fear of the patient dying. They should be reassured that this fear is normal. For those who only hint about this concern despite efforts to encourage them to talk about their fear, coaching may be helpful (eg, “Are you worrying about not making it through surgery? Most people who have heart surgery at least think about the possibility of dying.”). After the fear is expressed, the patient and family can be helped to explore their feelings. By alleviating undue anxiety and fear, preparing the patient emotionally for surgery decreases the chance of preoperative problems, promotes smooth anesthesia induction, and enhances the patient’s involvement in care and recovery after surgery. Preparing the family for the events to come helps them to cope, be supportive to the patient, and participate in postoperative and rehabilitative care (Chart 28-9). MONITORING AND MANAGING POTENTIAL COMPLICATIONS Angina may occur because of increased stress and anxiety related to the forthcoming surgery. The patient who develops angina usually responds to normal angina therapy, most commonly nitroglycerin. Some patients require oxygen and intravenous nitroglycerin drips (see the Angina Pectoris section).
Chapter 28
Chart 28-9
• Ethics and Related Issues
When Is Withholding or Withdrawing Life Support Discussed with Patients and Families? Situation Life support includes the use of intraaortic balloon pumps and ventricular assist devices, ventilators, vasoactive infusions, cardiopulmonary resuscitation, and antibiotics. Patients who receive these treatments include those who are acutely, chronically, and terminally ill. When dependent on life support, a patient may be unable to make decisions about his or her own care, and the patient’s family may be asked to participate in decision making for the patient. At what point is the sensitive issue of withholding or withdrawing life support discussed? Dilemma A patient is unresponsive and utilizing life support in the critical care unit. The consulting cardiologist has written a progress note stating, “Patient is terminal. Further treatment is futile.” The patient does not have a living will or a durable power of attorney for health care. The oldest child does not want the patient to suffer but states, “If there is any hope, I want everything done.” The other child states that the patient “would not want to live like this.” Does the statement by the second child support the principle of autonomy? Does the statement by the oldest child provide precedence for the principles of sanctity of life, beneficence, or nonmaleficence? If you determined that the statement by the second child supported the principle of autonomy, should sanctity of life, beneficence, or nonmaleficence be used in decision making in this situation? Discussion What arguments would you offer to support the view that discussions about the extent of life-supporting treatments desired should occur before an individual experiences a life-threatening event? What arguments would you offer to support the view that discussions about the extent of life-supporting treatment should occur only when certain circumstances arise?
For patients with extreme anxiety or fear and for whom emotional support and education are not successful, medication therapy may be helpful. The anxiolytic agents most commonly used before cardiac surgery are lorazepam (Ativan) and diazepam (Valium). If cardiac arrest occurs in the preoperative period, advanced cardiac life support is provided (see Chap. 27). PROMOTING HOME AND COMMUNITY-BASED CARE Teaching Patients Self-Care Patient and family teaching is based on assessed learning needs. Teaching usually includes information about hospitalization, surgery (eg, preoperative and postoperative care, length of surgery, pain and discomfort that can be expected, visiting hours, and procedures in the critical care unit), the recovery phase (eg, length of hospitalization, what to expect from home care and rehabilitation, when normal activities such as housework, shopping, and work can be resumed), and ongoing lifestyle habits. Any changes made in medical therapy and preoperative preparations need to be explained and reinforced. The patient is informed that physical preparation usually involves several showers or scrubs with an antiseptic solution. A sedative may be prescribed the night before and the morning of
Management of Patients With Coronary Vascular Disorders
747
surgery. Most cardiac surgical teams use prophylactic antibiotic therapy, and the antibiotic therapy is initiated before surgery. If no preadmission teaching has been done and the preoperative hospitalization period is very short, teaching the patient and family together may be most effective. Anxiety often increases with the admission process and impending surgery. Teaching the patient and family together capitalizes on their established support relationship. Teaching in this phase should be directed primarily by the patient’s and family’s questions. Too much detail may only increase anxiety. The patient may be offered a tour of the critical care unit, the postanesthesia care unit, or both. (In some hospitals, the patient initially goes to the postanesthesia care unit.) The patient recovering from anesthesia may be reassured by having already seen the surroundings and having met someone from the unit. The patient and family are informed about the equipment, tubes, and lines that will be present after surgery and their purposes. They should know to expect monitors, several intravenous lines, chest tubes, and a urinary catheter. Explaining the purpose and the approximate time that these devices will be in place helps to reassure the patient. Most patients will remain intubated and on mechanical ventilation for 2 to 24 hours after surgery. They need to be aware that this prevents them from talking, and they should be reassured that the staff will be able to assist them with other means of communication. The nurse takes care to answer the patient’s questions about postoperative care and procedures. Deep breathing and huffing (or coughing), use of the incentive spirometer, and foot exercises are explained and practiced by the patient before surgery. The family’s questions at this time usually focus on the length of the surgery, who will discuss the results of the procedure with them after surgery and when this may occur, where to wait during the surgery, the visiting procedures for the critical care unit, and how they can support the patient before surgery and in the critical care unit.
Evaluation EXPECTED PATIENT OUTCOMES Expected patient outcomes may include: 1. Demonstrates reduced fear a. Identifies fears b. Discusses fears with family c. Uses past experiences as a focus for comparison d. Expresses positive attitude about outcome of surgery e. Expresses confidence in measures to be used to relieve pain 2. Learns about the surgical procedure and postoperative course a. Identifies the purposes of the preoperative preparation procedure b. Tours the critical care unit, if desired c. Identifies limitations expected after surgery d. Discusses expected immediate postoperative environment (eg, tubes, machines, nursing surveillance) e. Demonstrates expected activities after surgery (eg, deep breathing, huffing [coughing], foot exercises) 3. Shows no evidence of complications a. Reports anginal pain is relieved with medications and rest b. Takes medications as prescribed
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Unit 6
CARDIOVASCULAR, CIRCULATORY, AND HEMATOLOGIC FUNCTION
INTRAOPERATIVE NURSING MANAGEMENT The perioperative nurse performs an assessment and prepares the patient for the operating room and recovery experience. Any changes in the patient’s status and the need for changes in therapy are identified. Procedures are explained before they are performed, such as the application of electrodes and use of continuous monitoring, indwelling catheters, and an SpO2 probe. Intravenous lines are inserted to administer fluids, medications, and blood products. The patient will receive general anesthesia, be intubated, and placed on mechanical ventilation. In addition to assisting with the surgical procedures, perioperative nurses are responsible for the comfort and safety of the patient. Some of the areas of intervention include positioning, skin care, wound care, and emotional support of the patient and family. Before the chest incision is closed, chest tubes are positioned to evacuate air and drainage from the mediastinum and the thorax. Epicardial pacemaker electrodes are implanted on the surface of the right atrium and the right ventricle. These epicardial electrodes can be used to pace the heart and to monitor it for dysrhythmias through the atrial leads. Possible intraoperative complications include dysrhythmias, hemorrhage, MI, CVA (stroke, brain attack), embolization, and organ failure from shock, embolus, or adverse drug reactions. Astute intraoperative patient assessment is critical in preventing these complications and for detecting symptoms and initiating prompt therapy.
NURSING PROCESS: THE PATIENT WHO HAS HAD CARDIAC SURGERY Initial postoperative care focuses on achieving or maintaining hemodynamic stability and recovery from general anesthesia. Care may be provided in the postanesthesia care unit or intensive care unit. After hemodynamic stability and recovery from general anesthesia have been achieved, the patient is transferred to a surgical stepdown unit with telemetry. Care focuses on wound care, progressive activity, and nutrition. Education about medications and risk factor modification is emphasized (see Plan of Nursing Care: Care of the Patient After Cardiac Surgery). Discharge from the hospital usually occurs 3 to 5 days after CABG or 1 to 3 days after MIDCAB. Patients can expect fewer symptoms from CAD and an improved quality of life. CABG has been shown to increase the life span of high-risk patients—those with left main artery blockages, left ventricular dysfunction with multivessel blockages, three-vessel blockages with one being the left anterior descending artery, and diabetes (Eagle et al., 1999). The immediate postoperative period for the patient who has undergone cardiac surgery presents many challenges to the health care team. All efforts are made to facilitate the transition from the operating room to the critical care unit or PACU with minimal risk. Specific information about the operation and important factors about postoperative management are communicated by the surgical team and anesthesia personnel to the critical care nurse, who then assumes responsibility for the patient’s care. Figure 28-10 presents a graphic overview of the many aspects of postoperative care for the cardiac surgical patient.
Assessment When the patient is admitted to the critical care unit or PACU and for at least every 12 hours thereafter, a complete assessment of all systems is performed to determine the postoperative status
of the patient compared with the preoperative baseline and to identify anticipated changes since surgery. The following parameters are assessed: Neurologic status: level of responsiveness, pupil size and reaction to light, reflexes, facial symmetry, movement of extremities, and hand grip strength Cardiac status: heart rate and rhythm, heart sounds, arterial blood pressure, central venous pressure (CVP), pulmonary artery pressure, pulmonary artery wedge pressure (PAWP), left atrial pressure, waveforms from the invasive blood pressure lines, cardiac output or index, systemic and pulmonary vascular resistance, pulmonary artery oxygen saturation (SvO2) if available, mediastinal chest tube drainage, and pacemaker status and function Respiratory status: chest movement, breath sounds, ventilator settings (eg, rate, tidal volume, oxygen concentration, mode such as synchronized intermittent mandatory ventilation, positive end-expiratory pressure, pressure support), respiratory rate, ventilatory pressure, arterial oxygen saturation (SaO2), percutaneous oxygen saturation (SpO2), end-tidal CO2, pleural chest tube drainage, arterial blood gases Peripheral vascular status: peripheral pulses; color of skin, nailbeds, mucosa, lips, and earlobes; skin temperature; edema; condition of dressings and invasive lines Renal function: urinary output; urine specific gravity and osmolality may be assessed Fluid and electrolyte status: intake, output from all drainage tubes, all cardiac output parameters, and the following indications of electrolyte imbalance: • Hypokalemia: digitalis toxicity, dysrhythmias, ECG changes (U wave, atrioventricular block, flat or inverted T waves) • Hyperkalemia: mental confusion, restlessness, nausea, weakness, paresthesias of extremities, dysrhythmias, ECG changes (tall, peaked T waves; increased amplitude, widening QRS complex; prolonged QT interval) • Hypomagnesemia: paresthesias, carpopedal spasm, muscle cramps, tetany, irritability, tremors, hyperexcitability, hyperreflexia, cardiac dysrhythmias, ECG changes (prolonged PR and QT intervals; broad, flat T waves), disorientation, depression, hypotension, seizures • Hypermagnesemia: vasodilation, hypotension, hyporeflexia, slow gastrointestinal motility (hypoactive bowel sounds), lethargy, respiratory depression, coma, apnea, cardiac arrest • Hyponatremia: weakness, fatigue, confusion, seizures, coma • Hypocalcemia: paresthesias, carpopedal spasm, muscle cramps, tetany • Hypercalcemia: digitalis toxicity, asystole Pain: nature, type, location, duration (incisional pain must be differentiated from anginal pain); apprehension; response to analgesics Some patients who have had a MIDCAB using a midsternal incision or an internal mammary artery CABG experience ulnar nerve paresthesia on the same side of the body as the graft. The paresthesia may be temporary or permanent. Patients who have had CABG using the gastroepiploic artery may experience an ileus for a longer period after surgery and have abdominal pain at the site of the incision and pain at the site of the chest incision. Assessment also includes observing all equipment and tubes to determine whether they are functioning properly: endotracheal tube, ventilator, end-tidal CO2 monitor, SpO2 monitor, pul-
Chapter 28 Nasogastric tube to decompress stomach. Endotracheal tube for providing ventilatory assistance, suctioning, and use of end-tidal CO2 monitor. Swan-Ganz catheter for monitoring central venous pressure, pulmonary artery and pulmonary artery wedge pressures, temperature, SvO2. Can be used for determining cardiac output, for venous and pulmonary artery blood sampling, and for medication administration. Venous lines can be used for fluid administration. Fluid intake is monitored.
Management of Patients With Coronary Vascular Disorders
749
Neurological assessment: • Level of responsiveness • Hand grasp • Pupils • Pain • Movement Assess skin color and temperature, color of lips, and color and capillary refill of nail beds. Epicardial pacing electrodes to temporarily pace the heart.
Mediastinal and pleural chest tubes attached to suction; drainage and wound healing are monitored.
ECG electrodes for monitoring heart rate and rhythm.
SpO2 monitor for measuring arterial oxygen saturation.
Assess peripheral pulses: radial, posterior tibial, dorsalis pedis.
Radial arterial line; used for monitoring arterial blood pressure and for blood sampling.
Indwelling catheter to closed drainage system for accurate measurement of urine output; a temperature probe may be part of the indwelling catheter.
FIGURE 28-10
Postoperative care of the cardiac surgical patient requires the nurse to be proficient in interpreting hemodynamics, correlating physical assessments with laboratory results, sequencing interventions, and evaluating progress toward desired outcomes.
monary artery catheter, Sv– O2 monitor, arterial and intravenous lines, intravenous infusion devices and tubing, cardiac monitor, pacemaker, chest tubes, and urinary drainage system. As the patient regains consciousness and progresses through the postoperative period, the nurse expands the assessment to include parameters indicative of psychological and emotional status. The patient may exhibit behavior that reflects denial or depression or may experience postcardiotomy psychosis. Characteristic signs of psychosis include transient perceptual illusions, visual and auditory hallucinations, disorientation, and paranoid delusions.
The family’s needs also should be assessed. The nurse ascertains how they are coping with the situation; determines their psychological, emotional, and spiritual needs; and finds out whether they are receiving adequate information about the patient’s condition. ASSESSING FOR COMPLICATIONS The patient is continuously assessed for indications of impending complications (Table 28-8). The nurse and the surgeon function collaboratively to identify early signs and symptoms of complications and to institute measures to reverse their progression. (text continues on page 754)
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Table 28-8 COMPLICATION
Unit 6
CARDIOVASCULAR, CIRCULATORY, AND HEMATOLOGIC FUNCTION
• Potential Complications of Cardiac Surgery DESCRIPTION
ASSESSMENT AND MANAGEMENT
Cardiac Complications (The patient may require interventions for more than one complication at a time. Collaboration among nurses, physicians, pharmacists, respiratory therapists, and dietitians is necessary to achieve the desired patient outcomes.) Decreased Cardiac Output Preload Alterations (the amount of myocardial muscle fiber stretch at the end of diastole) Hypovolemia (most common • Blood loss (although some blood may be replaced • Fluid replacement may be prescribed. Replacecause of decreased cardiac ment fluids include: colloid (albumin or protein), to provide sufficient hemoglobin to carry oxygen output after cardiac surgery) starch (hetastarch), packed red blood cells, or to the tissues) crystalloid solution (normal saline, lactated • Surgical hypothermia (As the reduced body temRinger’s solution). perature rises after surgery, blood vessels dilate, and more volume is needed to fill the vessels.) • Intravenous fluid loss to the interstitial spaces because cardiopulmonary bypass makes capillary beds more permeable • Arterial hypotension with low pulmonary artery wedge pressure (PAWP) and low central venous pressures (CVP) often are seen with an increased heart rate. Persistent bleeding • Accurate measurement of wound bleeding and • Cardiopulmonary bypass procedure, which may drainage tube blood is essential. Bloody drainage cause platelet malfunction (blood clots abnorshould not exceed 200 mL/h for the first 4 to mally) and hypothermia, which alters clotting 6 hours. Drainage should decrease and stop within mechanisms a few days, while progressing from sanguineous • Surgical trauma causing tissues and blood vessels to serosanguineous and serous drainage. to ooze bloody drainage • Protamine sulfate may be administered to neu• Anticoagulant (heparin) therapy tralize unfractionated heparin; vitamin K and blood products may be used to treat hematologic deficiencies. • If bleeding persists, the patient may return to the operating room for corrective surgery. Cardiac tamponade (may de• Equipment is checked to eliminate possible kinks • Fluid accumulates in the pericardial sac, which crease preload to the heart by or obstructions in the tubing. compresses the heart, preventing blood from fillpreventing available blood • Drainage system patency may be reestablished by ing the ventricles. from entering the heart) milking the tubing (taking care not to strip the • Signs and symptoms include arterial hypotension, tubing, creating massive negative pressure within tachycardia, muffled heart sounds, decreasing the chest, which may harm the surgical repair or urine output and equalizing of the PAWP, CVP, trigger a dysrhythmia). and pulmonary artery diastolic pressures. Additional signs and symptoms: arterial and pulmonary • Chest x-ray may show a widening mediastinum. • Emergency medical management is required; may artery pressure waveforms demonstrating a pulsus include pericardiocentesis or return to surgery. paradoxus (decrease of more than 10 mm Hg during inspiration) and decreased chest tube drainage (suggesting that the drainage is trapped or clotted in the mediastinum). Fluid overload • High PAWP, CVP, and pulmonary artery diastolic • Diuretics are usually prescribed and the rate of IV fluid administration is reduced. pressures as well as crackles indicate fluid overload. • Fluid restriction may be prescribed. Alternative treatments include continuous renal replacement therapy, dialysis, and phlebotomy. Afterload Alterations (The force that the ventricle must overcome to move blood forward. Vascular resistance may be calculated to assess afterload and the effects of any vasoactive treatments. Alteration in the patient’s body temperature is the most common cause of alterations in afterload after cardiac surgery.) Hypothermia • Patient is rewarmed gradually, although vasodila• Blood vessel constriction, which increases aftertors may be required if the resistance is too great load. (Blood vessel dilation from fever or other to wait for rewarming. The patient may require hyperthermic condition decreases afterload.) volume support or vasopressors during a fever or severe vasodilation. Hypertension • Vasodilators (nitroglycerin [Nitro-Bid], nitro• Various causes. Some patients have a history of prusside [Nipride, Nitropress]) may be used to this condition and the nurse can anticipate the treat hypertension. If patient had hypertension need for treatment postoperatively. Other patients before surgery, the preoperative management experience transient hypertension. regimen resumes as soon as possible. (continued)
Chapter 28
Table 28-8
Management of Patients With Coronary Vascular Disorders
751
• Potential Complications of Cardiac Surgery (Continued)
COMPLICATION
Heart Rate Alterations Tachydysrhythmias
DESCRIPTION
ASSESSMENT AND MANAGEMENT
• May or may not result from preload or afterload alterations
• Rhythms are assessed to establish that they are not the result of preload or afterload alterations. • If a tachydysrhythmia is the primary symptom, the heart rhythm is assessed and medications (eg, adenosine [Adenocard, Adenoscan], digoxin [Lanoxin], diltiazem [Cardizem], esmolol [Brevibloc], lidocaine [Xylocaine], procainamide [Procanbid, Pronestyl], propranolol [Inderal], quinidine [Cardioquin, Quinaglute, Quinidex], verapamil [Calan, Corvera, Isoptin, Verelan]) are prescribed. (Patients may be prescribed antiarrhythmics before CABG to minimize the risk of postoperative tachydysrhythmias.) • Carotid massage may be performed by a physician to assist with diagnosing or treating the dysrhythmia. • Cardioversion and defibrillation are alternatives for symptomatic tachydysrhythmias. • Many postoperative patients will have temporary pacer wires that can be attached to a pulse generator (pacemaker) to stimulate the heart to beat faster. Less commonly, atropine, epinephrine or isoproterenol may be used to increase heart rate. • Treatment may include medication (Table 27-1), pacemakers (antibradycardiac, antitachycardiac), carotid massage, cardioversion, or defibrillation. Goal of treatment is to return the heart to a normal sinus rhythm. • For patients who cannot attain normal sinus rhythm, an alternate goal may be to establish a stable rhythm that produces a sufficient cardiac output. • The nurse observes for and reports falling mean arterial pressure; rising PAWP, pulmonary artery diastolic pressure, and CVP; increasing tachycardia; restlessness and agitation; peripheral cyanosis; venous distention; labored respirations; and edema. • Medical management includes diuretics and digoxin. • Careful assessment to determine the type of pain the patient is experiencing; MI suspected if the mean blood pressure is low with normal preload. The systemic vascular resistance (afterload) and heart rate may be elevated to compensate for poor contractility. • Serial ECGs and cardiac enzymes assist in making the diagnosis (alterations may be due to the surgical intervention). Analgesics are prescribed in small amounts while the patient’s blood pressure and respiratory rate are monitored (because vasodilation secondary to analgesics or decreasing pain may occur and compound the hypotension). • Activity progression depends on the patient’s activity tolerance.
Bradycardias
• Decreased heart rate
Dysrhythmias (may or may not affect cardiac output)
• Abnormal heart rates
Contractility Alterations Cardiac failure
Myocardial infarction (may occur intraoperatively or postoperatively)
Pulmonary Complications Impaired gas exchange
• Possible when the heart fails as a pump and the chambers cannot adequately empty
• Portion of the cardiac muscle dies, therefore contractility decreases. Until the infarcted area becomes edematous, the ventricular wall moves paradoxically during contractions, further decreasing cardiac output. Symptoms may be masked by the postoperative surgical discomfort or the anesthesia–analgesia regimen.
• During and after anesthesia, patients require mechanical assistance to breathe. • Potential for postperative atelectasis. • Endotracheal tubes stimulate production of mucus and chest incision pain may decrease the effectiveness of the forced expiratory technique (FET, cough).
• Pulmonary complications are often detected during assessment of breath sounds, oxygen saturation levels, and end-tidal CO2 levels, and when monitoring peak pressure and exhaled tidal volumes on the ventilator. Arterial blood gas results and mixed venous saturations also are monitored when available. (continued)
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Table 28-8
Unit 6
CARDIOVASCULAR, CIRCULATORY, AND HEMATOLOGIC FUNCTION
• Potential Complications of Cardiac Surgery (Continued)
COMPLICATION
DESCRIPTION
ASSESSMENT AND MANAGEMENT
• Extended periods of mechanical ventilation are often required while the complications are treated and until they are resolved. • In patients with hypoxia, ventricular stroke work index may be calculated to assist with assessment of contractility. Fluid Volume Complications Hemorrhage
Neurologic Complications Cerebrovascular accident (brain attack, stroke)
• Untoward and excessive bleeding may be lifethreatening.
• Hemorrhage usually requires surgical intervention, and blood products are often administered. • Compression of a bleeding vessel is another treatment of hemorrhage. Lungs may be used to compress bleeding mediastinal blood vessels; lung volume and pressure are increased by adding PEEP to the ventilator settings of an intubated patient. The lungs slow or stop the bleeding by pushing in on the mediastinum and creating pressure on the bleeding vessels of the pericardium, coronary arteries, and bypass grafts.
• Inability to follow simple command within 6 hours of recovery from anesthetic; different capabilities on right or left side of body
• Neurologically, most patients begin to recover from anesthesia in the operating room. • Patients who are elderly or who have renal or hepatic failure may take longer to recover. • Patient should be evaluated for CVA (brain attack, stroke) or air embolism.
Pain (see Chapter 13) Renal Failure and Electrolyte Imbalance Renal failure • Usually acute and resolves within 3 months, but may become chronic and require ongoing dialysis Acute tubular necrosis • Often results from hypoperfusion of the kidneys or from injury to the renal tubules by medications in the filtrate or from exacerbation of a preexisting condition Hypokalemia (low potassium • May be caused by inadequate intake, diuretics, level; normal level is 3.5 to vomiting, diarrhea, excessive nasogastric 5.0 mEq/L [3.5 to drainage without potassium replacement, and 5.0 mmol/L]) stress due to surgery (increased aldosterone secretion produces decreased potassium and increased sodium retention). • Signs and symptoms: digitalis toxicity, dysrhythmias, metabolic alkalosis, a weakened myocardium, and cardiac arrest • One specific ECG change is a U wave (a positive deflection after the T wave) that is more than 1 mm high. Additional signs are atrioventricular block, flat or inverted T waves, and low voltage. Hyperkalemia (high potassium • Hyperkalemia may be caused by increased level) intake, red blood cell hemolysis caused by cardiopulmonary bypass or mechanical assist devices, acidosis, renal insufficiency, tissue necrosis, and adrenal cortical insufficiency. • Signs and symptoms: mental confusion, restlessness, nausea, weakness, and paresthesias of the extremities. • ECG changes specific for hyperkalemia are tall peaked T waves, increased amplitude and widening of the QRS complex, and a prolonged QT interval.
• May respond to diuretics or may require continuous renal replacement therapy (CRRT) or dialysis • Fluids, electrolytes, and urine output are monitored frequently.
• Must be detected and treated immediately • Patient must be observed carefully when serum potassium rises or falls outside the normal level • Some cardiac surgeons strive to maintain potassium level at 4.0 mEq/L (4.0 mmol/L) or higher to avoid dysrhythmias in the postoperative period. • When necessary, IV potassium replacement is prescribed.
• An ion exchange resin, sodium polystyrene sulfonate (Kayexalate), may be prescribed to bind the potassium in the gastrointestinal tract and decrease serum potassium. • Alternative treatments include IV sodium bicarbonate, IV insulin, and glucose to temporarily drive the potassium back into the cells from the extracellular fluid. • Hemodialysis or peritoneal dialysis may be used to reduce the potassium level.
(continued)
Chapter 28
Table 28-8
Management of Patients With Coronary Vascular Disorders
753
• Potential Complications of Cardiac Surgery (Continued)
COMPLICATION
DESCRIPTION
ASSESSMENT AND MANAGEMENT
Hypomagnesemia (low magnesium level, G or 1.5:1–2.5:1
Prothrombin Time
100% or 12–16 seconds
Serum Alkaline Phosphatase
Varies with method: 2–5 Bodansky units 30–50 IU/L at 34°C (17–142 U/L at 30°C) (20–90 U/L at 30°C)
Serum Aminotransferase or Transaminase Studies 10–40 units (4.8–19 U/L) AST (SGOT) 5–35 units (2.4–17 U/L) ALT (SGPT) GGT, GGTP LDH Serum Ammonia Cholesterol Ester HDL (high-density lipoprotein) LDL (low-density lipoprotein)
10–48 IU/L 100–200 units (100–225 U/L) 20–120 µg/dL (11.1–67.0 µmol/L) 150–250 mg/dL (3.90–6.50 mmol/L) 60% of total (fraction of total cholesterol: 0.60) HDL Male: 35–70 mg/dL, Female: 35–85 mg/dL LDL < 130 µg/dL
The studies are based on release of enzymes from damaged liver cells. These enzymes are elevated in liver cell damage. Elevated in alcohol abuse. Marker for biliary cholestasis. Liver converts ammonia to urea. Ammonia level rises in liver failure. Cholesterol levels are elevated in biliary obstruction and decreased in parenchymal liver disease.
ADDITIONAL STUDIES
CLINICAL FUNCTIONS
Barium study of esophagus Abdominal x-ray Liver scan with radiotagged iodinated rose bengal, gold, technetium, or gallium Cholecystogram and cholangiogram Celiac axis arteriography Splenoportogram (splenic portal venography) Laparoscopy
For varices, which indicate increased portal blood pressure To determine gross liver size To show size and shape of liver; to show replacement of liver tissue with scars, cysts, or tumor For gallbladder and bile duct visualization For liver and pancreas visualization To determine adequacy of portal blood flow Direct visualization of anterior surface of liver, gallbladder, and mesentery through a trocar To determine anatomic changes in liver tissue Elevated in cirrhosis of the liver To search for esophageal varices and other abnormalities Abnormal in hepatic coma and impending hepatic coma To show size of abdominal organs and presence of masses To detect hepatic neoplasms; diagnose cysts, abscesses, and hematomas; and distinguish between obstructive and nonobstructive jaundice. Detects cerebral atrophy in hepatic encephalopathy. Visualizes hepatic circulation and detects presence and nature of hepatic masses To detect hepatic neoplasms; diagnose cysts, abscesses, and hematomas. Detects cerebral atrophy in encephalopathy. Visualizes biliary structures via endoscopy
Liver biopsy (percutaneous or transjugular) Measurement of portal pressure Esophagoscopy/endoscopy Electroencephalogram Ultrasonography Computed tomography (CT scan) Angiography Magnetic resonance imaging (MRI) Endoscopic retrograde cholangiopancreatography (ERCP)
Unit 8
1080
METABOLIC AND ENDOCRINE FUNCTION
Chart 39-1 GUIDELINES FOR Assisting With Percutaneous Liver Biopsy NURSING ACTIVITIES
RATIONALE
PREPROCEDURE 1. Ascertain that results of coagulation tests (prothrombin time, partial thromboplastin time, and platelet count) are available and that compatible donor blood is available. 2. Check for signed consent; confirm that informed consent has been provided. 3. Measure and record the patient’s pulse, respirations, and blood pressure immediately before biopsy. 4. Describe to the patient in advance: steps of the procedure; sensations expected; after-effects anticipated; restrictions of activity and monitoring procedures to follow.
Many patients with liver disease have clotting defects and are at risk for bleeding.
Prebiopsy values provide a basis on which to compare the patient’s vital signs and evaluate status after the procedure. Explanations allay fears and ensure cooperation.
DURING PROCEDURE 5. Support the patient during the procedure. 6. Expose the right side of the patient’s upper abdomen (right hypochondriac). 7. Instruct the patient to inhale and exhale deeply several times, finally to exhale, and to hold breath at the end of expiration. The physician promptly introduces the biopsy needle by way of the transthoracic (intercostal) or transabdominal (subcostal) route, penetrates the liver, aspirates, and withdraws. 8. Instruct the patient to resume breathing.
Encouragement and support of the nurse enhance comfort and promote a sense of security. The skin at the site of penetration will be cleansed and a local anesthetic will be infiltrated. Holding the breath immobilizes the chest wall and the diaphragm; penetration of the diaphragm thereby is avoided, and the risk of lacerating the liver is minimized.
Lung 6th rib Diaphragm
Liver 7th rib
POSTPROCEDURE 9. Immediately after the biopsy, assist the patient to turn onto the right side; place a pillow under the costal margin, and caution the patient to remain in this position, recumbent and immobile, for several hours. Instruct the patient to avoid coughing or straining. 10. Measure and record the patient’s pulse, respiratory rate, and blood pressure at 10- to 15-minute intervals for the first hour, then every 30 minutes for the next 1 to 2 hours or until the patient’s condition stabilizes. 11. If the patient is discharged after the procedure, instruct the patient to avoid heavy lifting and strenuous activity for 1 week.
In this position, the liver capsule at the site of penetration is compressed against the chest wall, and the escape of blood or bile through the perforation is prevented.
Changes in vital signs may indicate bleeding, severe hemorrhage, or bile peritonitis, the most frequent complications of liver biopsy. Activity restriction reduces the risk of bleeding at the biopsy puncture site.
Chapter 39
Assessment and Management of Patients With Hepatic Disorders
OTHER DIAGNOSTIC TESTS Ultrasonography, computed tomography (CT), and magnetic resonance imaging (MRI) are used to identify normal structures and abnormalities of the liver and biliary tree. A radioisotope liver scan may be performed to assess liver size and hepatic blood flow and obstruction. Laparoscopy (insertion of a fiber-optic endoscope through a small abdominal incision) is used to examine the liver and other pelvic structures. It is also used to perform guided liver biopsy, to determine the etiology of ascites, and to diagnose and stage tumors of the liver and other abdominal organs.
Hepatic Dysfunction Hepatic dysfunction results from damage to the liver’s parenchymal cells, either directly from primary liver diseases or indirectly from obstruction of bile flow or derangements of hepatic circulation. Liver dysfunction may be acute or chronic; chronic dysfunction is far more common than acute. Chronic liver disease, including cirrhosis, is the seventh most common cause of death in the United States among young and middle-aged adults. More than 40% of those deaths are associated with alcohol. The rate of chronic liver disease for men is twice that for women, and chronic liver disease is more common among African Americans than Caucasians. Disease processes that lead to hepatocellular dysfunction may be caused by infectious agents such as bacteria and viruses and by anoxia, metabolic disorders, toxins and medications, nutritional deficiencies, and hypersensitivity states. The most common cause of parenchymal damage is malnutrition, especially that related to alcoholism. The parenchymal cells respond to most noxious agents by replacing glycogen with lipids, producing fatty infiltration with or without cell death or necrosis. This is commonly associated with inflammatory cell infiltration and growth of fibrous tissue. Cell regeneration can occur if the disease process is not too toxic to the cells. The result of chronic parenchymal disease is the shrunken, fibrotic liver seen in cirrhosis. The consequences of liver disease are numerous and varied. Their ultimate effects are often incapacitating or life-threatening, and their presence is ominous. Treatment often is difficult. Among the most common and significant symptoms of liver disease are the following:
• Jaundice, resulting from increased bilirubin concentration in the blood
• Portal hypertension, ascites, and varices, resulting from circu•
•
latory changes within the diseased liver and producing severe GI hemorrhages and marked sodium and fluid retention Nutritional deficiencies, which result from the inability of the damaged liver cells to metabolize certain vitamins; responsible for impaired functioning of the central and peripheral nervous systems and for abnormal bleeding tendencies Hepatic encephalopathy or coma, reflecting accumulation of ammonia in the serum due to impaired protein metabolism by the diseased liver
JAUNDICE When the bilirubin concentration in the blood is abnormally elevated, all the body tissues, including the sclerae and the skin, become yellow-tinged or greenish-yellow, a condition called jaun-
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dice. Jaundice becomes clinically evident when the serum bilirubin level exceeds 2.5 mg/dL (43 fmol/L). Increased serum bilirubin levels and jaundice may result from impairment of hepatic uptake, conjugation of bilirubin, or excretion of bilirubin into the biliary system. There are several types of jaundice: hemolytic, hepatocellular, obstructive, or jaundice due to hereditary hyperbilirubinemia. Hepatocellular and obstructive jaundice are the two types commonly associated with liver disease.
Hemolytic Jaundice Hemolytic jaundice is the result of an increased destruction of the red blood cells, the effect of which is to flood the plasma with bilirubin so rapidly that the liver, although functioning normally, cannot excrete the bilirubin as quickly as it is formed. This type of jaundice is encountered in patients with hemolytic transfusion reactions and other hemolytic disorders. The bilirubin in the blood of these patients is predominantly of the unconjugated, or free, type. Fecal and urine urobilinogen levels are increased, but the urine is free of bilirubin. Patients with this type of jaundice, unless their hyperbilirubinemia is extreme, do not experience symptoms or complications as a result of the jaundice per se. Prolonged jaundice, however, even if mild, predisposes to the formation of pigment stones in the gallbladder, and extremely severe jaundice (levels of free bilirubin exceeding 20 to 25 mg/dL) poses a risk for brain stem damage.
Hepatocellular Jaundice Hepatocellular jaundice is caused by the inability of damaged liver cells to clear normal amounts of bilirubin from the blood. The cellular damage may be from infection, such as in viral hepatitis (eg, hepatitis A, B, C, D, or E) or other viruses that affect the liver (eg, yellow fever virus, Epstein-Barr virus), from medication or chemical toxicity (eg, carbon tetrachloride, chloroform, phosphorus, arsenicals, certain medications), or from alcohol. Cirrhosis of the liver is a form of hepatocellular disease that may produce jaundice. It is usually associated with excessive alcohol intake, but it may also be a late result of liver cell necrosis caused by viral infection. In prolonged obstructive jaundice, cell damage eventually develops, so that both types appear together. Patients with hepatocellular jaundice may be mildly or severely ill, with lack of appetite, nausea, malaise, fatigue, weakness, and possible weight loss. In some cases of hepatocellular disease, jaundice may not be obvious. The serum bilirubin concentration and urine urobilinogen level may be elevated. In addition, AST and ALT levels may be increased, indicating cellular necrosis. The patient may report headache, chills, and fever if the cause is infectious. Depending on the cause and extent of the liver cell damage, hepatocellular jaundice may or may not be completely reversible.
Obstructive Jaundice Obstructive jaundice of the extrahepatic type may be caused by occlusion of the bile duct by a gallstone, an inflammatory process, a tumor, or pressure from an enlarged organ. The obstruction may also involve the small bile ducts within the liver (ie, intrahepatic obstruction), caused, for example, by pressure on these channels from inflammatory swelling of the liver or by an inflammatory exudate within the ducts themselves. Intrahepatic obstruction resulting from stasis and inspissation (thickening) of bile within the canaliculi may occur after the ingestion of certain medications,
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which are referred to as cholestatic agents. These include phenothiazines, antithyroid medications, sulfonylureas, tricyclic antidepressant agents, nitrofurantoin, androgens, and estrogens. Whether the obstruction is intrahepatic or extrahepatic, and whatever its cause may be, bile cannot flow normally into the intestine but is backed up into the liver substance. It is then reabsorbed into the blood and carried throughout the entire body, staining the skin, mucous membranes, and sclerae. It is excreted in the urine, which becomes deep orange and foamy. Because of the decreased amount of bile in the intestinal tract, the stools become light or clay-colored. The skin may itch intensely, requiring repeated soothing baths. Dyspepsia and intolerance to fatty foods may develop because of impaired fat digestion in the absence of intestinal bile. AST, ALT, and GGT levels generally rise only moderately, but bilirubin and alkaline phosphatase levels are elevated.
Hereditary Hyperbilirubinemia Increased serum bilirubin levels (hyperbilirubinemia) resulting from several inherited disorders can also produce jaundice. Gilbert’s syndrome is a familial disorder characterized by an increased level of unconjugated bilirubin that causes jaundice. Although serum bilirubin levels are increased, liver histology and liver function test results are normal, and there is no hemolysis. This syndrome affects 2% to 5% of the population. Other conditions that are probably caused by inborn errors of biliary metabolism include Dubin–Johnson syndrome (chronic idiopathic jaundice, with pigment in the liver) and Rotor’s syndrome (chronic familial conjugated hyperbilirubinemia without pigment in the liver); “benign” cholestatic jaundice of pregnancy, with retention of conjugated bilirubin, probably secondary to unusual sensitivity to the hormones of pregnancy; and probably also benign recurrent intrahepatic cholestasis.
creased intravascular fluid volume, and decreased synthesis of albumin by the damaged liver all contribute to fluid moving from the vascular system into the peritoneal space. Loss of fluid into the peritoneal space causes further sodium and water retention by the kidney in an effort to maintain the vascular fluid volume, and the process becomes self-perpetuating. As a result of liver damage, large amounts of albumin-rich fluid, 15 L or more, may accumulate in the peritoneal cavity as ascites. With the movement of albumin from the serum to the peritoneal cavity, the osmotic pressure of the serum decreases. This, combined with increased portal pressure, results in movement of fluid into the peritoneal cavity (Fig. 39-4).
Clinical Manifestations Increased abdominal girth and rapid weight gain are common presenting symptoms of ascites. The patient may be short of breath and uncomfortable from the enlarged abdomen, and striae and distended veins may be visible over the abdominal wall. Fluid and electrolyte imbalances are common.
Assessment and Diagnostic Evaluation The presence and extent of ascites are assessed by percussion of the abdomen. When fluid has accumulated in the peritoneal cavity, the flanks bulge when the patient assumes a supine position. The presence of fluid can be confirmed either by percussing for shifting dullness or by detecting a fluid wave (Fig. 39-5). A fluid wave is likely to be found only when a large amount of fluid is present.
Physiology/Pathophysiology
PORTAL HYPERTENSION Obstructed blood flow through the damaged liver results in increased blood pressure (portal hypertension) throughout the portal venous system. Although portal hypertension is commonly associated with hepatic cirrhosis, it can also occur with noncirrhotic liver disease. While splenomegaly (enlarged spleen) with possible hypersplenism is a common manifestation of portal hypertension, two major consequences of portal hypertension are ascites and varices. In ascites, fluid accumulates in the abdominal cavity. Although ascites is often a result of liver damage, it may also occur with disorders such as cancer, kidney disease, and heart failure. Varices are varicosities that develop from elevated pressures transmitted to all of the veins that drain into the portal system. They are prone to rupture and often are the source of massive hemorrhages from the upper GI tract and the rectum. In addition, blood clotting abnormalities, often seen in patients with severe liver disease, increase the likelihood of bleeding.
ASCITES Pathophysiology The mechanisms responsible for the development of ascites are not completely understood. Portal hypertension and the resulting increase in capillary pressure and obstruction of venous blood flow through the damaged liver are contributing factors. The failure of the liver to metabolize aldosterone increases sodium and water retention by the kidney. Sodium and water retention, in-
Cirrhosis with portal hypertension
Splanchnic arterial vasodilation
Decrease in circulating arterial blood volume
Activation of renin-angiotensin and sympathetic nervous systems and antidiuretic hormone
Kidney retains sodium and water
Hypervolemia
Persistent activation of systems for retention of sodium and water; ascites and edema formation
Continued arterial underfilling; cycle repeats
FIGURE 39-4
Pathogenesis of ascites (arterial vasodilation theory).
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blocking agent, is most often the first-line therapy in patients with ascites from cirrhosis. When used with other diuretics, spironolactone helps prevent potassium loss. Oral diuretics such as furosemide (Lasix) may be added but should be used cautiously because with long-term use they may also induce severe sodium depletion (hyponatremia). Ammonium chloride and acetazolamide (Diamox) are contraindicated because of the possibility of precipitating hepatic coma. Daily weight loss should not exceed 1 to 2 kg (2.2 to 4.4 lb) in patients with ascites and peripheral edema or 0.5 to 0.75 kg (1.1 to 1.65 lb) in patients without edema. Fluid restriction is not attempted unless the serum sodium concentration is very low. Possible complications of diuretic therapy include fluid and electrolyte disturbances (including hypovolemia, hypokalemia, hyponatremia, and hypochloremic alkalosis) and encephalopathy. Encephalopathy may be precipitated by dehydration and hypovolemia. Also, when potassium stores are depleted, the amount of ammonia in the systemic circulation increases, which may cause impaired cerebral functioning and encephalopathy.
FIGURE 39-5 Assessing for abdominal fluid wave. The examiner places the hands along the side of the patient’s flank, then strikes one flank sharply, detecting any fluid wave with the other hand. An assistant’s hand is placed (ulnar side down) along the patient’s midline to prevent the fluid wave from being transmitted through the tissues of the abdominal wall. Daily measurement and recording of abdominal girth and body weight are essential to assess the progression of ascites and its response to treatment.
Medical Management DIETARY MODIFICATION The goal of treatment for the patient with ascites is a negative sodium balance to reduce fluid retention. Table salt, salty foods, salted butter and margarine, and all ordinary canned and frozen foods (foods that are not specifically prepared for low-sodium diets) should be avoided. It may take 2 to 3 months for the patient’s taste buds to adjust to unsalted foods. In the meantime, the taste of unsalted foods can be improved by using salt substitutes such as lemon juice, oregano, and thyme. Commercial salt substitutes need to be approved by the physician because those containing ammonia could precipitate hepatic coma. Most salt substitutes contain potassium and should be avoided if the patient has impaired renal function. The patient should make liberal use of powdered, low-sodium milk and milk products. If fluid accumulation is not controlled with this regimen, the daily sodium allowance may be reduced further to 500 mg, and diuretics may be administered. Dietary control of ascites via strict sodium restriction is difficult to achieve at home. The likelihood that the patient will follow even a 2-g sodium diet increases if the patient and the person preparing meals understand the rationale for the diet and receive periodic guidance about selecting and preparing appropriate foods. Approximately 10% of patients with ascites respond to these measures alone. Nonresponders and those who find sodium restriction difficult require diuretic therapy. DIURETICS Use of diuretics along with sodium restriction is successful in 90% of patients with ascites. Spironolactone (Aldactone), an aldosterone-
BED REST In patients with ascites, an upright posture is associated with activation of the renin-angiotensin-aldosterone system and sympathetic nervous system (Porth, 2002). This results in reduced renal glomerular filtration and sodium excretion and a decreased response to loop diuretics. Bed rest may be a useful therapy, especially for patients whose condition is refractory to diuretics. PARACENTESIS Paracentesis is the removal of fluid (ascites) from the peritoneal cavity through a small surgical incision or puncture made through the abdominal wall under sterile conditions. Ultrasound guidance may be indicated in some patients at high risk for bleeding because of an abnormal coagulation profile or in those who have had previous abdominal surgery and who may have adhesions. Paracentesis was once considered a routine form of treatment for ascites but is now performed primarily for diagnostic examination of ascitic fluid, for treatment of massive ascites that is resistant to nutritional and diuretic therapy and that is causing severe problems to the patient, and as a prelude to diagnostic imaging studies, peritoneal dialysis, or surgery. A sample of the ascitic fluid may be sent to the laboratory for analysis. Cell count, albumin and total protein levels, culture, and occasionally other tests are performed. Use of large-volume (5 to 6 liters) paracentesis has been shown to be a safe method for treating patients with severe ascites. This technique, in combination with the intravenous infusion of saltpoor albumin or other colloid, has become the standard treatment for refractory, massive ascites (Krige & Beckingham, 2001; Menon & Kamath, 2000). The salt-poor albumin helps reduce edema by causing the ascitic fluid to be drawn back into the bloodstream and ultimately eliminated by the kidneys. The procedure provides only temporary removal of fluid; it rapidly recurs, necessitating repeated removal. Nursing care of the patient undergoing paracentesis is presented in Chart 39-2. OTHER METHODS OF TREATMENT Insertion of a peritoneovenous shunt to redirect ascitic fluid from the peritoneal cavity into the systemic circulation is a treatment modality for ascites, but this procedure is seldom used because of the high complication rate and high incidence of shunt failure. The shunt is reserved for those who are resistant to diuretic therapy, are not candidates for liver transplantation, have abdominal adhesions, or are ineligible for other procedures because of severe medical conditions, such as cardiac disease.
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Chart 39-2
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Assisting With a Paracentesis
Preprocedure 1. Prepare the patient by providing the necessary information and instructions about the procedure and by offering reassurance. 2. Instruct the patient to void. 3. Gather appropriate sterile equipment and collection receptacles. 4. Place patient in upright position on edge of bed with feet supported on stool, or place in chair. Fowler’s position should be used for the patient confined to bed. 5. Place sphygmomanometer cuff around patient’s arm to allow monitoring of blood pressure during the procedure. Procedure 1. The physician, using aseptic technique, inserts the trocar through a puncture wound below the umbilicus. The fluid drains from the abdomen through a drainage tube into a container. 2. Help the patient maintain position throughout procedure. 3. Measure and record blood pressure at frequent intervals from the beginning of the procedure. 4. Monitor the patient closely for signs of vascular collapse: pallor, increased pulse rate, or decreased blood pressure.
Postprocedure 1. Return patient to bed or to a comfortable sitting position. 2. Measure, describe, and record the fluid collected. 3. Label samples of fluid and send to laboratory. 4. Continue to monitor vital signs every 15 minutes for 1 hour, every 30 minutes over 2 hours, then every hour over 2 hours and then every 4 hours. Monitor temperature after procedure and every 4 hours. 5. Assess for hypovolemia, electrolyte loss, changes in mental status, and encephalopathy. 6. Check puncture site when taking vital signs for bleeding and leakage. 7. Provide patient education (especially if patient is discharged after procedure) regarding monitoring for bleeding or excess drainage from puncture site, avoiding heavy lifting or straining, changing position slowly, and monitoring for fever.
Figure on left shows possible sites for insertion of trocar.
Nursing Management If a patient with ascites from liver dysfunction is hospitalized, nursing measures include assessment and documentation of intake and output, abdominal girth, and daily weight to assess fluid status. The nurse monitors serum ammonia and electrolyte levels to assess electrolyte balance, response to therapy, and indicators of encephalopathy. PROMOTING HOME AND COMMUNITY-BASED CARE Teaching Patients Self-Care. The patient treated for ascites is likely to be discharged with some ascites still present. Before hospital discharge, the nurse teaches the patient and family about the treatment plan, including the need to avoid all alcohol intake, adhere to a low-sodium diet, take medications as prescribed, and
check with the physician before taking any new medications (Chart 39-3). Additional patient and family teaching addresses skin care and the need to weigh the patient daily and to watch for and report signs and symptoms of complications. Continuing Care. A referral for home care may be warranted, especially if the patient lives alone or cannot provide self-care. The home visit enables the nurse to assess changes in the patient’s condition and weight, abdominal girth, skin, and cognitive and emotional status. The home care nurse assesses the home environment and the availability of resources needed to adhere to the treatment plan (eg, a scale to obtain daily weights, facilities to prepare and store appropriate foods, resources to purchase needed medications). It is important to assess the patient’s adherence to the treatment plan and the ability to buy, prepare, and eat
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Chart 39-3 Home Care Checklist • Management of Ascites At the completion of the home care instruction, the patient or caregiver will be able to: • Make appropriate dietary choices consistent with dietary prescription and recommendations. • State the importance of weighing self daily and keeping a daily record of weight. • Maintain record of weight daily and identify daily weight-loss goals. • List weight changes (loss or gain) that should be reported to the primary health care provider. • Explain the rationale for monitoring and recording daily intake and output. • Identify changes in output that should be reported to primary health care provider (decreasing urine output). • Identify rationale for fluid restrictions (if needed), and comply with fluid restriction. • Discuss importance of avoiding nonsteroidal anti-inflammatory agents, medications (eg, cough mixtures) containing alcohol, antibiotics or antacids containing salt. • Describe effects, side effects, and monitoring parameters for diuretic therapy. • Identify need to stop all alcohol intake as critical to well-being. • Explain how to contact Alcoholics Anonymous or alcohol counselors in related organizations. • Demonstrate how to care for skin, alleviate pressure over bony prominences by turning when in bed or chair, and decrease edema by position changes. • Identify early signs and symptoms of complications (encephalopathy, spontaneous bacterial peritonitis, dehydration, electrolyte abnormalities, azotemia).
appropriate foods. The nurse reinforces previous teaching and emphasizes the need for regular follow-up and the importance of keeping scheduled health care appointments.
ESOPHAGEAL VARICES Bleeding or hemorrhage from esophageal varices occurs in approximately one third of patients with cirrhosis and varices. The mortality rate resulting from the first bleeding episode is 45% to 50%; it is one of the major causes of death in patients with cirrhosis (Pomier-Layrargues, Villeneuve, Deschenes et al., 2001). The mortality rate increases with each subsequent bleeding episode.
Patient
Caregiver
✓ ✓ ✓ ✓ ✓ ✓ ✓
✓ ✓ ✓ ✓ ✓ ✓ ✓
✓ ✓ ✓ ✓
✓ ✓ ✓ ✓
✓
✓
✓
✓
vomiting; esophagitis; irritation of vessels by poorly chewed foods or irritating fluids; or reflux of stomach contents (especially alcohol). Salicylates and any medication that erodes the esophageal mucosa or interferes with cell replication also may contribute to bleeding.
Clinical Manifestations The patient with bleeding esophageal varices may present with hematemesis, melena, or general deterioration in mental or physical status and often has a history of alcohol abuse. Signs and
Physiology/Pathophysiology
Pathophysiology Esophageal varices are dilated, tortuous veins usually found in the submucosa of the lower esophagus, but they may develop higher in the esophagus or extend into the stomach. This condition nearly always is caused by portal hypertension, which in turn is due to obstruction of the portal venous circulation within the damaged liver. Because of increased obstruction of the portal vein, venous blood from the intestinal tract and spleen seeks an outlet through collateral circulation (new pathways of return to the right atrium). The effect is increased pressure, particularly in the vessels in the submucosal layer of the lower esophagus and upper part of the stomach. These collateral vessels are not very elastic but rather are tortuous and fragile and bleed easily (Fig. 39-6). Less common causes of varices are abnormalities of the circulation in the splenic vein or superior vena cava and hepatic venothrombosis. Bleeding esophageal varices are life-threatening and can result in hemorrhagic shock, producing decreased cerebral, hepatic, and renal perfusion. In turn, there is an increased nitrogen load from bleeding into the GI tract and an increased serum ammonia level, increasing the risk for encephalopathy. Usually the dilated veins cause no symptoms unless the portal pressure increases sharply and the mucosa or supporting structures become thin. Then massive hemorrhage takes place. Factors that contribute to hemorrhage are muscular exertion from lifting heavy objects; straining at stool; sneezing, coughing, or
Portal hypertension (caused by resistance to portal flow and increased portal venous inflow)
Development of pressure gradient of 12 mm Hg or greater between portal vein and inferior vena cava (portal pressure gradient)
Venous collaterals develop from high portal system pressure to systemic veins in esophageal plexus, hemorrhoidal plexus and retroperitoneal veins
Abnormal varicoid vessels form in any of above locations
Vessels may rupture causing life-threatening hemorrhage.
FIGURE 39-4
Pathogenesis of bleeding esophageal varices.
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symptoms of shock (cool clammy skin, hypotension, tachycardia) may be present.
Assessment and Diagnostic Findings Endoscopy is used to identify the bleeding site, along with barium swallow, ultrasonography, CT, and angiography. ENDOSCOPY Immediate endoscopy (see Chap. 34) is indicated to identify the cause and the site of bleeding; at least 30% of patients suspected of bleeding from esophageal varices bleed from other sources (gastritis, ulcers). Nursing support can be effective in relieving anxiety during this often-stressful experience. Careful monitoring can detect early signs of cardiac dysrhythmias, perforation, and hemorrhage. After the examination, fluids are not given until the gag reflex returns. Lozenges and gargles may be used to relieve throat discomfort if the patient’s physical condition and mental status permit. If the patient is actively bleeding, oral intake will not be permitted and the patient will be prepared for further diagnostic and therapeutic procedures. PORTAL HYPERTENSION MEASUREMENTS Portal hypertension may be suspected if dilated abdominal veins and hemorrhoids are detected. A palpable enlarged spleen (splenomegaly) and ascites may also be present. Portal venous pressure can be measured directly or indirectly. Indirect measurement of the hepatic vein pressure gradient is the most common procedure; it requires insertion of a fluid-filled balloon catheter into the antecubital or femoral vein. The catheter is advanced under fluoroscopy to a hepatic vein. A “wedged” pressure (similar to pulmonary artery wedge pressure) is obtained by occluding the blood flow in the blood vessel; pressure in the unoccluded vessel is also measured. Although the values obtained may underestimate portal pressure, this measurement may be obtained several times to evaluate the results of therapy. Direct measurement of portal vein pressure can be obtained by several methods. During laparotomy, a needle may be introduced into the spleen; a manometer reading of more than 20 mL saline is abnormal. Another direct measurement requires insertion of a catheter into the portal vein or one of its branches. Endoscopic measurement of pressure within varices is used only in conjunction with endoscopic sclerotherapy. LABORATORY TESTS Laboratory tests may include various liver function tests, such as serum aminotransferase, bilirubin, alkaline phosphatase, and serum proteins. Splenoportography, which involves serial or segmental x-rays, is used to detect extensive collateral circulation in esophageal vessels, which would indicate varices. Other tests are hepatoportography and celiac angiography. These are usually performed in the operating room or radiology department.
Medical Management Bleeding from esophageal varices can quickly lead to hemorrhagic shock and is an emergency. This patient is critically ill, requiring aggressive medical care and expert nursing care, and is usually transferred to the intensive care unit for close monitoring and management. See Chapter 15 for a discussion of care of the patient in shock. The extent of bleeding is evaluated and vital signs are monitored continuously when hematemesis and melena are present. Signs of
potential hypovolemia are noted, such as cold clammy skin, tachycardia, a drop in blood pressure, decreased urine output, restlessness, and weak peripheral pulses. Blood volume is monitored by a central venous pressure or arterial catheter. Oxygen is administered to prevent hypoxia and to maintain adequate blood oxygenation. Because patients with bleeding esophageal varices have intravascular volume depletion and are subject to electrolyte imbalance, intravenous fluids with electrolytes and volume expanders are provided to restore fluid volume and replace electrolytes. Transfusion of blood components also may be required. An indwelling urinary catheter is usually inserted to permit frequent monitoring of urine output. A variety of pharmacologic, endoscopic, and surgical approaches are used to treat bleeding esophageal varices, but none is ideal and most are associated with considerable risk to the patient. Nonsurgical treatment of bleeding esophageal varices is preferable because of the high mortality rate of emergency surgery for control of bleeding esophageal varices and because of the poor physical condition of the patient with severe liver dysfunction. PHARMACOLOGIC THERAPY In an actively bleeding patient, medications are administered initially because they can be obtained and administered quickly; other therapies take longer to initiate. Vasopressin (Pitressin) may be the initial mode of therapy because it produces constriction of the splanchnic arterial bed and a resulting decrease in portal pressure. It may be administered intravenously or by intra-arterial infusion (Menon & Kamath, 2000). Either method requires close monitoring by the nurse. Vital signs and the presence or absence of blood in the gastric aspirate indicate the effectiveness of vasopressin. Monitoring of fluid intake and output and electrolyte levels is necessary because hyponatremia may occur and vasopressin may have an antidiuretic effect. Coronary artery disease is a contraindication to the use of vasopressin, because coronary vasoconstriction is a side effect that may precipitate myocardial infarction. The combination of vasopressin and nitroglycerin (administered by the intravenous, sublingual, or transdermal route) has been effective in reducing or preventing the side effects (constriction of coronary vessels and angina) caused by vasopressin alone. Somatostatin and octreotide (Sandostatin) have been reported to be more effective than vasopressin in decreasing bleeding from esophageal varices without the vasoconstrictive effects of vasopressin. These medications cause selective splanchnic vasoconstriction. Propranolol (Inderal) and nadolol (Corgard), beta-blocking agents that decrease portal pressure, have been shown to prevent bleeding from esophageal varices in some patients; however, it is recommended that they be used only in combination with other treatment modalities such as sclerotherapy, variceal banding, or balloon tamponade. Nitrates such as isosorbide (Isordil) lower portal pressure by venodilation and decreased cardiac output. Further studies of these and other medications are necessary to evaluate their use in the treatment and prevention of bleeding episodes. BALLOON TAMPONADE To control hemorrhage in certain patients, balloon tamponade may be used. In this procedure, pressure is exerted on the cardia (upper orifice of the stomach) and against the bleeding varices by a double-balloon tamponade (Sengstaken-Blakemore tube) (Fig. 39-7). The tube has four openings, each with a specific purpose: gastric aspiration, esophageal aspiration, inflation of the gastric balloon, and inflation of the esophageal balloon. The balloon in the stomach is inflated with 100 to 200 mL of air. An x-ray confirms proper positioning of the gastric balloon. Then the tube is pulled gently to exert a force against the gastric
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Sponge
1. To esophageal balloon
2. Esophageal aspirate
3. To gastric balloon 4. Gastric aspirate
Esophageal varices
A
B
C
FIGURE 39-7 Esophageal balloon tamponade to treat esophageal varices. (A) Dilated, bleeding esophageal veins (varices) of the lower esophagus. (B) A four-lumen esophageal tamponade tube with balloons (uninflated) in place. (C ) Compression of bleeding esophageal varices by inflated esophageal and gastric balloons. The gastric and esophageal outlets permit the nurse to aspirate secretions.
cardia. Traction may be applied with weights or by attachment to a football helmet. Irrigation of the tubing is performed to detect bleeding; if returns are clear, the esophageal balloon is not inflated. If bleeding continues, the esophageal balloon is inflated. The desired pressure in the esophageal and gastric balloons is 25 to 40 mm Hg, as measured by the manometer. There is a possibility of injury or rupture of the esophagus with inflation of the esophageal balloon, so constant nursing surveillance is necessary. Gastric suction is provided by connecting the gastric catheter outlet to suction. The tubing is irrigated hourly, and drainage will indicate whether bleeding has been controlled. Room-temperature lavage or irrigation may be used in the gastric balloon. The pressure within the esophageal balloon is measured and recorded every 2 to 4 hours via the manometer to detect underinflation or overinflation with potential for esophageal injury. When it appears that bleeding has stopped, the balloons are carefully and sequentially deflated. The esophageal balloon is deflated first and the patient is monitored for recurrent bleeding. After several hours without bleeding, the gastric balloon may be deflated safely. If there is still no bleeding, the tamponade tube is removed. The therapy is used for as short a time as possible to control bleeding while emergency treatment is completed and definitive therapies are instituted (no longer than 24 hours).
Although balloon tamponade has been fairly successful, there are some inherent dangers. Displacement of the tube and the inflated balloon into the oropharynx can cause life-threatening obstruction of the airway and asphyxiation. This may occur if a patient pulls on the tube because of confusion or discomfort. It may also result from rupture of the gastric balloon, allowing the esophageal balloon to move into the oropharynx. Sudden rupture of the balloon causes airway obstruction and aspiration of gastric contents into the lungs. The tube is tested before insertion to minimize this risk. Aspiration of blood and secretions into the lungs is frequently associated with balloon tamponade, especially in the stuporous or comatose patient. Endotracheal intubation before insertion of the tube protects the airway and minimizes the risk of aspiration. Ulceration and necrosis of the nose, the mucosa of the stomach, or the esophagus may occur if the tube is left in place or inflated too long or at too high a pressure.
!
NURSING ALERT The patient being treated with balloon tamponade must never be left alone because of the risk for serious complications. The patient must be monitored closely and continuously. Precautions must be taken to ensure that the patient does not pull on or inadvertently displace the tube.
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These potential complications necessitate intensive and expert care. A confused or restless patient with this tube in place and balloons inflated requires close monitoring to prevent its displacement. Nursing measures include frequent mouth and nasal care. For secretions that accumulate in the mouth, tissues should be within easy reach of the patient. Oral suction may be necessary to remove oral secretions. Because of the many potential complications, balloon tamponade tubes are used only as a temporary measure. The patient with esophageal hemorrhage is usually extremely anxious and frightened. Knowing that the nurse is nearby and will respond immediately can help alleviate some of this anxiety. Tube insertion is uncomfortable and never pleasant. Explanations during the procedure and while the tube is in place may be reassuring to the patient. Although the use of balloon tamponade stops the bleeding in 90% of patients, bleeding recurs in 60% to 70%, necessitating other treatment modalities (eg, sclerotherapy or banding) (Menon & Kamath, 2000). Once the balloons are deflated or the tube is removed, the patient must be assessed frequently because of the high risk for recurrent bleeding. ENDOSCOPIC SCLEROTHERAPY In endoscopic sclerotherapy (Fig. 39-8) (also referred to as injection sclerotherapy), a sclerosing agent is injected through a fiberoptic endoscope into the bleeding esophageal varices to promote thrombosis and eventual sclerosis. The procedure has been used successfully to treat acute GI hemorrhage (Menon & Kamath, 2000; O’Grady et al., 2000). Endoscopic variceal sclerotherapy has been used in the primary prophylaxis of variceal bleeding, but the results are poorer than those of pharmacotherapy (Sarin, Lamba, Kumar et al., 1999). After treatment, the patient must be observed for bleeding, perforation of the esophagus, aspiration pneumonia, and esophageal stricture. Antacids may be administered after the procedure to counteract the effects of peptic reflux. ESOPHAGEAL BANDING THERAPY (VARICEAL BAND LIGATION) In variceal banding (Fig. 39-9), a modified endoscope loaded with an elastic rubber band is passed through an overtube directly onto the varix (or varices) to be banded. After suctioning the bleeding varix into the tip of the endoscope, the rubber band is slipped over the tissue, causing necrosis, ulceration, and eventual sloughing of the varix.
Endoscope
Injection needle Esophageal varices
Esophagus
Stomach
FIGURE 39-8 Endoscopic or injection sclerotherapy. Injection of sclerosing agent into esophageal varices through an endoscope promotes thrombosis and eventual sclerosis, thereby obliterating the varices.
Variceal banding is comparable to endoscopic sclerotherapy in the effective control of bleeding. Compared with sclerotherapy, variceal banding also significantly reduces rebleeding rates, mortality, procedure-related complications, and the number of sessions needed to eradicate varices. Complications include superficial ulceration and dysphagia, transient chest discomfort, and rarely esophageal strictures (Menon & Kamath, 2000). Recently, endoscopic variceal band ligation has been shown to be safe and more effective than propanolol for preventing a first bleeding episode (Sarin et al., 1999). TRANSJUGULAR INTRAHEPATIC PORTOSYSTEMIC SHUNTING Transjugular intrahepatic portosystemic shunting (TIPS) is a method of treating esophageal varices in which a cannula is threaded into the portal vein by the transjugular route. An expandable stent is inserted and serves as an intrahepatic shunt between the portal circulation and the hepatic vein (Fig. 39-10), reducing portal hypertension. Creation of a TIPS is indicated for the treatment of recurrent variceal bleeding refractory to pharmacologic or endoscopic therapy. It has also been indicated for the control of refractory ascites. This technique is also used as a bridge to liver transplantation. Complications may include bleeding, sepsis, heart failure, organ perforation, shunt thrombosis, and progressive liver failure (PomierLayrargues et al., 2001). SURGICAL MANAGEMENT Several surgical procedures have been developed to treat esophageal varices and to minimize rebleeding, but they are often accompanied by significant risk. Procedures that may be used for esophageal varices are direct surgical ligation of varices; splenorenal, mesocaval, and portacaval venous shunts to relieve portal pressure; and esophageal transection with devascularization. Use of these procedures is controversial, and studies regarding their effectiveness and outcomes are ongoing (Bacon & Di Bisceglie, 2000). Surgical Bypass Procedures. Surgical decompression of the portal circulation can prevent variceal bleeding if the shunt remains patent (Bacon & Di Bisceglie, 2000). One of the various surgical shunting procedures (Fig. 39-11) is the distal splenorenal shunt made between the splenic vein and the left renal vein after splenectomy. A mesocaval shunt is created by anastomosing the superior mesenteric vein to the proximal end of the vena cava or to the side of the vena cava using grafting material. The goal of distal splenorenal and mesocaval shunts is to drain only a portion of venous blood from the portal bed to decrease portal pressure; thus, they are considered selective shunts. The liver continues to receive some portal flow, and the incidence of encephalopathy may be reduced. Portacaval shunts divert all portal flow to the vena cava via end-to-side or side-to-side approaches, so they are considered nonselective shunts. These procedures are extensive and are not always successful because of secondary thrombosis in the veins used for the shunt as well as complications (eg, encephalopathy, accelerated liver failure). The efficacy of these procedures has been studied extensively. The most recent studies have found that all shunts are equally effective in preventing recurrent variceal bleeding but may cause further impairment of liver function and encephalopathy. Partial portacaval shunts with interposition grafts are as effective as other shunts but are associated with a lower rate of encephalopathy (de Franchis, 2000; Krige & Beckingham, 2001; Orozco & Mercado, 2000). The severity of the disease (by Child’s classification) and the
Chapter 39
Assessment and Management of Patients With Hepatic Disorders
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Esophagus Esophagus free of endoscope
Endoscope Suction applicator
Sloughing varix
Varix
Ligating band
Ligating band
FIGURE 39-9 A
Esophageal banding. (A) A rubber band–like ligature is slipped over an esophageal varix via an endoscope. (B) Necrosis results and the varix eventually sloughs off.
B
potential for future liver transplantation guide the physician’s choice of intervention. If the cause of portal hypertension is the rare Budd-Chiari syndrome or other venous obstructive disease, a portacaval or a mesoatrial shunt may be performed (see Fig. 39-11). The mesoatrial shunt is required when the infrahepatic vena cava is thrombosed and must be bypassed. Devascularization and Transection. Devascularization and staplegun transection procedures to separate the bleeding site from the high-pressure portal system have been used in the emergency management of variceal bleeding. The lower end of the esophagus is reached through a small gastrostomy incision; a staple gun permits anastomosis of the transected ends of the esophagus. Rebleeding is a risk, and the outcomes of these procedures vary among patient populations.
!
NURSING ALERT Postoperative care is similar to that for any abdominal surgery, but the risk for complications (hypovolemic or hemorrhagic shock, hepatic encephalopathy, electrolyte imbalance, metabolic and respiratory alkalosis, alcohol withdrawal syndrome, and seizures) is high. The surgical procedures do not alter the course of the progressive liver disease, and bleeding may recur as new collateral vessels develop.
Nursing Management Overall nursing assessment includes monitoring the patient’s physical condition and evaluating emotional responses and cognitive status. The nurse monitors and records vital signs and assesses the patient’s nutritional and neurologic status. This assessment will assist in identifying hepatic encephalopathy resulting from the breakdown of blood in the GI tract and a rising serum ammonia level. Manifestations range from drowsiness to encephalopathy and coma. Complete rest of the esophagus may be indicated with bleeding, so parenteral nutrition is initiated. Gastric suction usually is
Spleen
Portal veins Kidney Inferior vena cava
Liver
A
Normal system
C
Splenorenal shunt
End-to-side portacaval shunt
B
Catheter Hepatic vein
Guide wire Stent in place Portal vein
FIGURE 39-10 Transjugular intrahepatic portosystemic shunt (TIPS). A stent is inserted via catheter to the portal vein to divert blood flow and reduce portal hypertension.
D
Mesocaval shunt
FIGURE 39-11 Portal systemic shunts. Normal portal system is shown in (A); examples of portal shunts to reduce portal pressure are shown in (B) to (D).
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initiated to keep the stomach as empty as possible and to prevent straining and vomiting. The patient often complains of severe thirst, which may be relieved by frequent oral hygiene and moist sponges to the lips. The nurse closely monitors the blood pressure. Vitamin K therapy and multiple blood transfusions often are indicated because of blood loss. A quiet environment and calm reassurance may help to relieve the patient’s anxiety and reduce agitation. Bleeding anywhere in the body is anxiety-provoking, resulting in a crisis for the patient and family. If the patient has been a heavy user of alcohol, delirium secondary to alcohol withdrawal can complicate the situation. The nurse provides support and explanations regarding medical and nursing interventions. Monitoring the patient closely will help in detecting and managing complications.
Table 39-2
Management modalities and nursing care of the patient with bleeding esophageal varices are summarized in Table 39-2.
HEPATIC ENCEPHALOPATHY AND COMA Hepatic encephalopathy, a life-threatening complication of liver disease, occurs with profound liver failure and may result from the accumulation of ammonia and other toxic metabolites in the blood. Hepatic coma represents the most advanced stage of hepatic encephalopathy. Some researchers describe a false or weak neurotransmitter as a cause, but the exact mechanism is not fully understood. These false neurotransmitters may be generated from an intestinal source and result in the precipitation of encephalopathy. Many other theories exist about the causes of encephalopathy, including excess tryptophan and its metabolites,
• Management Modalities and Nursing Care for the Patient With Bleeding Esophageal Varices
TREATMENT MODALITY*
Nonsurgical Modalities Pharmacologic agents Vasopressin (Pitressin)
ACTION
NURSING PRIORITIES
Reduces portal pressure by constricting splanchnic arteries
Observe response to therapy. Monitor for side effects: vasopressin—angina; nitroglycerin may be prescribed to prevent or treat angina. propranolol and nadolol—decreased pulse pressure, impaired cardiovascular response to hemorrhage. Support patient during treatment. Explain procedure to patient briefly to obtain cooperation with insertion and maintenance of esophageal tamponade tube and reduce patient’s fear of the procedure. Monitor closely to prevent inadvertent removal or displacement of tube, subsequent airway obstruction, and aspiration. Provide frequent oral hygiene. Ensure patency of the nasogastric tube to prevent aspiration. Observe gastric aspirate for blood and cessation of bleeding. Observe for aspiration, perforation of the esophagus, and recurrence of bleeding after treatment. Observe for recurrence of bleeding, esophageal perforation. Observe for rebleeding and signs of infection.
Propranolol (Inderal)/nadolol (Corgard)
Reduces portal pressure by β-adrenergic blocking action
Somatostatin/octreotide (Sandostatin)
Reduces portal pressure by selective vasodilation of portal system Exerts pressure directly to bleeding sites in esophagus and stomach
Balloon tamponade
Room-temperature saline lavage
Clears blood and secretions before endoscopy and other procedures
Injection sclerotherapy
Promotes thrombosis and sclerosing of bleeding sites by injection of sclerosing agent into the esophageal varices Provides thrombosis and mucosal necrosis of bleeding sites by band ligation Reduces portal pressure by creating a shunt within the liver between the portal and systemic venous system.
Variceal banding Transjugular intrahepatic portosystemic shunting (TIPS) Surgical Modalities Portal-systemic shunting
Surgical ligation of varices Esophageal transection and devascularization
*Several modalities may be used concurrently or in sequence.
Reduces portal hypertension by diverting blood flow away from obstructed portal system
Ties off blood vessels at the site of bleeding Separates bleeding site from portal system
Observe for development of portal-systemic encephalopathy (altered mental status, neurologic dysfunction), hepatic failure, and rebleeding. Requires intensive, expert nursing care for prolonged period. Observe for rebleeding. Observe for rebleeding. Provide postthoracotomy care.
Chapter 39
Assessment and Management of Patients With Hepatic Disorders
and endogenous benzodiazepines or opiates. Benzodiazepine-like chemicals (compounds) have been detected in the plasma and cerebrospinal fluid of patients with hepatic encephalopathy due to cirrhosis (Bacon & Di Bisceglie, 2000). Portal-systemic encephalopathy, the most common type of hepatic encephalopathy, occurs primarily in patients with cirrhosis with portal hypertension and portal-systemic shunting.
Pathophysiology Ammonia accumulates because damaged liver cells fail to detoxify and convert to urea the ammonia that is constantly entering the bloodstream. Ammonia enters the bloodstream as a result of its absorption from the GI tract and its liberation from kidney and muscle cells. The increased ammonia concentration in the blood causes brain dysfunction and damage, resulting in hepatic encephalopathy. Circumstances that increase serum ammonia levels tend to aggravate or precipitate hepatic encephalopathy. The largest source of ammonia is the enzymatic and bacterial digestion of dietary and blood proteins in the GI tract. Ammonia from these sources is increased as a result of GI bleeding (ie, bleeding esophageal varices or chronic GI bleeding), a high-protein diet, bacterial infections, and uremia. The ingestion of ammonium salts also increases the blood ammonia level. In the presence of alkalosis or hypokalemia, increased amounts of ammonia are absorbed from the GI tract and from the renal tubular fluid. Conversely, serum ammonia is decreased by elimination of protein from the diet and by the administration of antibiotic agents, such as neomycin sulfate, that reduce the number of intestinal bacteria capable of converting urea to ammonia (Dudek, 2001). Other factors unrelated to increased serum ammonia levels that may cause hepatic encephalopathy in susceptible patients include excessive diuresis, dehydration, infections, surgery, fever, and some medications (sedative agents, tranquilizers, analgesic agents, and diuretic medications that cause potassium loss). Table 39-3 presents the stages of hepatic encephalopathy, common signs and symptoms, and potential nursing diagnoses for each stage.
Table 39-3
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Clinical Manifestations The earliest symptoms of hepatic encephalopathy include minor mental changes and motor disturbances. The patient appears slightly confused, has alterations in mood, becomes unkempt, and has altered sleep patterns. The patient tends to sleep during the day and have restlessness and insomnia at night. As hepatic encephalopathy progresses, the patient may be difficult to awaken. Asterixis (flapping tremor of the hands) may occur (Fig. 39-12). Simple tasks, such as handwriting, become difficult. A handwriting or drawing sample (eg, star figure), taken daily, may provide graphic evidence of progression or reversal of hepatic encephalopathy. Inability to reproduce a simple figure (Fig. 39-13) is referred to as constructional apraxia. In the early stages of hepatic encephalopathy, the deep tendon reflexes are hyperactive; with worsening of hepatic encephalopathy, these reflexes disappear and the extremities may become flaccid.
Assessment and Diagnostic Findings The electroencephalogram (EEG) shows generalized slowing, an increase in the amplitude of brain waves, and characteristic triphasic waves. Occasionally, fetor hepaticus, a sweet, slightly fecal odor to the breath presumed to be of intestinal origin may be noticed. The odor has also been described as similar to that of freshly mowed grass, acetone, or old wine. Fetor hepaticus is prevalent with extensive collateral portal circulation in chronic liver disease. In a more advanced stage, there are gross disturbances of consciousness and the patient is completely disoriented with respect to time and place. With further progression of the disorder, the patient lapses into frank coma and may have seizures. Approximately 35% of all patients with cirrhosis of the liver die in hepatic coma.
Medical Management Lactulose (Cephulac) is administered to reduce serum ammonia levels. It acts by several mechanisms that promote the excretion of ammonia in the stool: (1) ammonia is kept in the ionized state, resulting in a fall in colon pH, reversing the normal passage of ammonia from the colon to the blood; (2) evacuation of the bowel takes place, which decreases the ammonia
• Stages of Hepatic Encephalopathy and Possible Nursing Diagnoses*
STAGE
CLINICAL SYMPTOMS
CLINICAL SIGNS AND EEG CHANGES
SELECTED POTENTIAL NURSING DIAGNOSES
1
Normal level of consciousness with periods of lethargy and euphoria; reversal of day–night sleep patterns Increased drowsiness; disorientation; inappropriate behavior; mood swings; agitation Stuporous; difficult to rouse; sleeps most of time; marked confusion; incoherent speech Comatose; may not respond to painful stimuli
Asterixis; impaired writing and ability to draw line figures. Normal EEG.
Activity intolerance Self-care deficit Disturbed sleep pattern Impaired social interaction Ineffective role performance Risk for injury Imbalanced nutrition Impaired mobility Impaired verbal communication Risk for aspiration Impaired gas exchange Impaired tissue integrity Disturbed sensory perception
2
3
4
Asterixis; fetor hepaticus. Abnormal EEG with generalized slowing. Asterixis; increased deep tendon reflexes; rigidity of extremities. EEG markedly abnormal. Absence of asterixis; absence of deep tendon reflexes; flaccidity of extremities. EEG markedly abnormal.
*Nursing diagnoses are likely to progress, so that most nursing diagnoses present at earlier stages will occur during later stages as well.
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to which some patients object, lactulose can be diluted with fruit juice. The patient is closely monitored for hypokalemia and dehydration. Other laxatives are not prescribed during lactulose administration because their effects would disturb dosage regulation. Lactulose can be administered by nasogastric tube or enema for patients who are comatose or in whom oral administration is contraindicated or impossible. Other aspects of management include intravenous administration of glucose to minimize protein breakdown, administration of vitamins to correct deficiencies, and correction of electrolyte imbalances (especially potassium). Additional principles of management of hepatic encephalopathy include the following:
• Therapy is directed toward treating or removing the cause. • Neurologic status is assessed frequently. A daily record is • • •
FIGURE 39-12
Asterixis or “liver flap” may occur in hepatic encephalopathy. The patient is asked to hold the arm out with the hand held upward (dorsiflexed). Within a few seconds, the hand falls forward involuntarily and then quickly returns to the dorsiflexed position.
absorbed from the colon; and (3) the fecal flora are changed to organisms that do not produce ammonia from urea. Two or three soft stools per day are desirable; this indicates that lactulose is performing as intended.
!
NURSING ALERT The patient receiving lactulose is monitored closely for the development of watery diarrheal stools, because they indicate a medication overdose.
Possible side effects include intestinal bloating and cramps, which usually disappear within a week. To mask the sweet taste,
• • • • • •
kept of handwriting and performance in arithmetic to monitor mental status. Fluid intake and output and body weight are recorded each day. Vital signs are measured and recorded every 4 hours. Potential sites of infection (peritoneum, lungs) are assessed frequently, and abnormal findings are reported promptly. Serum ammonia level is monitored daily. Protein intake is restricted in patients who are comatose or who have encephalopathy that is refractory to lactulose and antibiotic therapy (Chart 39-4). Reduction in the absorption of ammonia from the GI tract is accomplished by the use of gastric suction, enemas, or oral antibiotics. Electrolyte status is monitored and corrected if abnormal. Sedatives, tranquilizers, and analgesic medications are discontinued. Benzodiazepine antagonists (flumazenil [Romazicon]) may be administered to improve encephalopathy whether or not the patient has previously taken benzodiazepines.
Nursing Management The nurse is responsible for maintaining a safe environment to prevent injury, bleeding, and infection. The nurse administers the prescribed treatments and monitors the patient for the many potential complications. The nurse also communicates with the pa-
Chart 39-4
Nutritional Management of Hepatic Encephalopathy
• Prevent the formation and absorption of toxins, principally ammonia, from the intestine.
• Keep daily protein intake between 1.0 and 1.5 g/kg, depending on the degree of decompensation.
• Avoid protein restriction if possible, even in those with
FIGURE 39-13 Effects of constructional apraxia. Deterioration of handwriting and inability to draw a simple star figure occurs with progressive hepatic encephalopathy. With permission from Sherlock S. & Dooley, J. (1997). Diseases of the liver and biliary system (10th ed). Olney Mead, Blackwell Scientific Ltd.
encephalopathy. If necessary, implement temporary restriction of 0.5 g/kg. • For patients who are truly protein-intolerant, provide additional nitrogen in the form of an amino acid supplement. Use of branched-chain amino acids is still controversial. • Provide small, frequent meals and an evening snack of complex carbohydrates to avoid protein loading. • Substitute vegetable protein for animal protein in as high a percentage as possible.
Chapter 39
Assessment and Management of Patients With Hepatic Disorders
tient’s family to keep them informed about the patient’s status, and supports them by explaining the procedures and treatments that are part of the patient’s care. If the patient recovers from hepatic encephalopathy and coma, rehabilitation is likely to be prolonged. Thus, the patient and family will require assistance to understand the causes of this severe complication and to recognize that it may recur. PROMOTING HOME AND COMMUNITY-BASED CARE Teaching Patients Self-Care. If the patient has recovered from hepatic encephalopathy and is to be discharged home, the nurse instructs the family to watch for subtle signs of recurrent encephalopathy. In the acute phase of hepatic encephalopathy, dietary protein may be reduced to 0.8 to 1.0 g/kg per day. During recovery, and in the home situation, it is important to instruct the patient in maintenance of a low-protein, high-calorie diet. Protein may then be added in 10-g increments every 3 to 5 days. Any relapse is treated by a return to the previous level. The limits of tolerance are usually 40 to 60 g/day (1.0 to 1.5 g/kg per day). Continued use of lactulose in the home environment is not uncommon, and the patient and family should monitor its efficacy and side effects closely. Use of vegetable rather than animal protein may be indicated in patients whose total daily protein tolerance is less than 1 g/kg. Vegetable protein intake may result in improved nitrogen balance without precipitating or advancing hepatic encephalopathy (Menon & Kamath, 2000; Seymour & Whelan, 1999). Continuing Care. Referral for home care is warranted for the patient who returns home after recovery from hepatic encephalopathy. The home care nurse assesses the patient’s physical and mental status and collaborates closely with the physician. The home visit also provides an opportunity for the nurse to assess the home environment and the ability of the patient and family to monitor signs and symptoms and to follow the treatment regimen. Home care visits are particularly important if the patient lives alone, because encephalopathy may affect the patient’s ability to remember or follow the treatment regimen. The nurse reinforces previous teaching and reminds the patient and family about the importance of dietary restrictions, close monitoring, and follow-up.
OTHER MANIFESTATIONS OF LIVER DYSFUNCTION Edema and Bleeding Many patients with liver dysfunction develop generalized edema from hypoalbuminemia that results from decreased hepatic production of albumin. The production of blood clotting factors by the liver is also reduced, leading to an increased incidence of bruising, epistaxis, bleeding from wounds, and, as described above, GI bleeding.
Vitamin Deficiency Decreased production of several clotting factors may be due, in part, to deficient absorption of vitamin K from the GI tract. This probably is caused by the inability of liver cells to use vitamin K to make prothrombin. Absorption of the other fat-soluble vitamins (vitamins A, D, and E) as well as dietary fats may also be impaired because of decreased secretion of bile salts into the intestine.
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Another group of problems common to patients with severe chronic liver dysfunction results from inadequate intake of sufficient vitamins. Among the specific deficiency states that occur on this basis are:
• Vitamin A deficiency, resulting in night blindness and eye and skin changes
• Thiamine deficiency, leading to beriberi, polyneuritis, and Wernicke-Korsakoff psychosis
• Riboflavin deficiency, resulting in characteristic skin and mucous membrane lesions
• Pyridoxine deficiency, resulting in skin and mucous membrane lesions and neurologic changes
• Vitamin C deficiency, resulting in the hemorrhagic lesions of scurvy
• Vitamin K deficiency, resulting in hypoprothrombinemia, characterized by spontaneous bleeding and ecchymoses
• Folic acid deficiency, resulting in macrocytic anemia The threat of these avitaminoses provides the rationale for supplementing the diet of every patient with chronic liver disease (especially if alcohol-related) with ample quantities of vitamins A, B complex, C, and K and folic acid.
Metabolic Abnormalities Abnormalities of glucose metabolism also occur; the blood glucose level may be abnormally high shortly after a meal (a diabetictype glucose tolerance test result), but hypoglycemia may occur during fasting because of decreased hepatic glycogen reserves and decreased gluconeogenesis. Because the ability to metabolize medications is decreased, medications must be used cautiously and usual medication dosages must be reduced for the patient with liver failure. Many endocrine abnormalities also occur with liver dysfunction because the liver cannot metabolize hormones normally, including androgens or sex hormones. Gynecomastia, amenorrhea, testicular atrophy, loss of pubic hair in the male, and menstrual irregularities in the female and other disturbances of sexual function and sex characteristics are thought to result from failure of the damaged liver to inactivate estrogens normally.
Pruritus and Other Skin Changes Patients with liver dysfunction resulting from biliary obstruction commonly develop severe itching (pruritus) due to retention of bile salts. Patients may develop vascular (or arterial) spider angiomas (Fig. 39-14) on the skin, generally above the waistline. These are numerous small vessels resembling a spider’s legs. These are most frequently associated with cirrhosis, especially in alcoholic liver disease. Patients may also develop reddened palms (“liver palms” or palmar erythema).
Management of Patients With Viral Hepatic Disorders VIRAL HEPATITIS Viral hepatitis is a systemic, viral infection in which necrosis and inflammation of liver cells produce a characteristic cluster of clinical, biochemical, and cellular changes. To date, five definitive
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lic health concern. The disease is important because it is easy to transmit, has high morbidity, and causes prolonged loss of time from school or employment. It is estimated that 60% to 90% of cases of viral hepatitis go unreported. The occurrence of subclinical cases, failure to recognize mild cases, and misdiagnosis are thought to contribute to the underreporting. Although approximately 40% of all persons in the United States have antibodies against hepatitis A virus, many cannot recall an earlier episode or the occurrence of the symptoms of hepatitis (O’Grady et al., 2000). Table 39-4 compares the major forms of viral hepatitis.
HEPATITIS A VIRUS (HAV)
FIGURE 39-14 Spider angioma. This vascular (arterial) spider appears on the skin. Beneath the elevated center and radiating branches, the blood vessels are looped and tortuous. types of viral hepatitis have been identified: hepatitis A, B, C, D, and E. Hepatitis A and E are similar in mode of transmission (fecal–oral route), whereas hepatitis B, C, and D share many characteristics. Terms associated with viral hepatitis are listed in Chart 39-5. The increasing incidence of viral hepatitis is a pub-
Chart 39-5
HAV accounts for 20% to 25% of cases of clinical hepatitis in the developed world. Hepatitis A, formerly called infectious hepatitis, is caused by an RNA virus of the Enterovirus family. The mode of transmission of this disease is the fecal–oral route, primarily through the ingestion of food or liquids infected by the virus. The virus has been found in the stool of infected patients before the onset of symptoms and during the first few days of illness. Typically, a child or a young adult acquires the infection at school by poor hygiene, hand-to-mouth contact, or close contact at play. The virus is carried home, where haphazard sanitary habits spread it through the family. It is more prevalent in developing countries or in areas with overcrowding and poor sanitation. An infected food handler can spread the disease, and people can contract it by consuming water or shellfish from sewage-contaminated waters. Outbreaks have occurred in day care centers and institutions for the developmentally delayed because of lapses in hygiene. It is rarely, if ever, transmitted by blood transfusions. Hepatitis A can be transmitted during sexual activity; this is more likely with
Hepatitis Terms and Abbreviations
Hepatitis A HAV Anti-HAV IgM anti-HAV Hepatitis B HBV HBsAG Anti-HBs
Hepatitis A virus; etiologic agent of hepatitis A (formerly infectious hepatitis) Antibody to hepatitis A virus; appears in serum soon after onset of symptoms; disappears after 3–12 months IgM antibody to HAV; indicates recent infection with HAV; positive up to 6 months after infection
IgM anti-HBc
Hepatitis B virus; etiologic agent of hepatitis B (formerly serum hepatitis) Hepatitis B surface antigen (Australian antigen); indicates acute or chronic hepatitis B or carrier state; indicates infectious state Antibody to hepatitis B surface antigen; indicates prior exposure and immunity to hepatitis; may indicate passive antibody from HBIG or immune response from hepatitis B vaccine Hepatitis B e-antigen; present in serum early in course; indicates highly infectious stage of hepatitis B; persistence in serum indicates progression to chronic hepatitis Antibody to hepatitis B e-antigen; suggests low titer of HBV Hepatitis B core antigen; found in liver cells; not easily detected in serum Antibody to hepatitis B core antigen; most sensitive indicator of hepatitis B; appears late in the acute phase of the disease; indicates infection of HBV at some time in the past IgM antibody to HBcAg; present for up to 6 months after HBV infection
Hepatitis C HCV
Hepatitis C virus (formerly non-A, non-B virus); may be more than one virus
Hepatitis D HDV HDAg Anti-HDV
Hepatitis D virus (delta agent); etiologic agent to hepatitis D; HBV required for replication Hepatitis delta antigen; detectable in early acute HDV infection Antibody to HDV; indicates past or present infection with HDV
Hepatitis E HEV
Hepatitis E virus; etiologic agent of hepatitis E
Hepatitis G HGV
Hepatitis G virus; also known as GB virus C
HBeAg Anti-HBe HBcAg Anti-HBc
Chapter 39
Table 39-4
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• Comparison of Major Forms of Viral Hepatitis
Previous names Epidemiology Cause Mode of transmission
Incubation (days) Immunity
Nature of Illness Signs and symptoms
Outcome
Assessment and Management of Patients With Hepatic Disorders
HEPATITIS A
HEPATITIS B
HEPATITIS C
Infectious hepatitis
Serum hepatitis
Non-A, non-B hepatitis
Hepatitis A virus (HAV) Fecal–oral route; poor sanitation. Person-to-person contact. Waterborne; foodborne. Transmission possible with oral–anal contact during sex.
Hepatitis B virus (HBV) Parenterally; by intimate contact with carriers or those with acute disease; sexual and oral–oral contact. Perinatal transmission from mothers to infants. An important occupational hazard for health care personnel. 28–160 days Average: 70–80 days Homologous
15–50 days Average: 30 days Homologous
May occur with or without symptoms; flulike illness Preicteric phase: Headache, malaise, fatigue, anorexia, fever Icteric phase: Dark urine, jaundice of sclera and skin, tender liver Usually mild with recovery. Fatality rate: 90%) who contract hepatitis B infections will develop antibodies and recover spontaneously in 6 months. The mortality rate from hepatitis B has been reported to be as high as 10%. Another 10% of patients who have hepatitis B progress to a carrier state or develop chronic hepatitis with persistent HBV infection and hepatocellular injury and inflammation. It remains a major cause of cirrhosis and hepatocellular carcinoma worldwide (Chart 39-8).
Chart 39-8
Risk Factors for Hepatitis B • Frequent exposure to blood, blood products, or other body fluids • Health care workers: hemodialysis staff, oncology and chemo• • • • • • • •
therapy nurses, personnel at risk for needlesticks, operating room staff, respiratory therapists, surgeons, dentists Hemodialysis Male homosexual and bisexual activity IV/injection drug use Close contact with carrier of HBV Travel to or residence in area with uncertain sanitary conditions Multiple sexual partners Recent history of sexually transmitted disease Receipt of blood or blood products (eg, clotting factor concentrate)
inner core)
• HBsAg—hepatitis B surface antigen (antigenic material on surface of HBV)
• HBeAg—an independent protein circulating in the blood • HBxAg—gene product of X gene of HBV/DNA Each antigen elicits its specific antibody and is a marker for different stages of the disease process:
• anti-HBc—antibody to core antigen or HBV; persists dur• • •
ing the acute phase of illness; may indicate continuing HBV in the liver anti-HBs—antibody to surface determinants on HBV; detected during late convalescence; usually indicates recovery and development of immunity anti-HBe—antibody to hepatitis B e-antigen; usually signifies reduced infectivity anti-HBxAg—antibody to the hepatitis B x-antigen; may indicate ongoing replication of HBV
HBsAg appears in the circulation in 80% to 90% of infected patients 1 to 10 weeks after exposure to HBV and 2 to 8 weeks before the onset of symptoms or an increase in transferase (transaminase) levels. Patients with HBsAg that persists for 6 or more months after acute infection are considered HBsAg carriers (Befeler & Di Bisceglie, 2000). HBeAg is the next antigen of HBV to appear in the serum. It usually appears within a week of the appearance of HBsAg and before changes in aminotransferase levels, disappearing from the serum within 2 weeks. HBV DNA, detected by polymerase chain reaction testing, appears in the serum at about the same time as HBeAg. HBcAg is not always detected in the serum in HBV infection. About 15% of American adults are positive for anti-HBs, which indicates that they have had hepatitis B. Anti-HBs may be positive in as many as two thirds of IV/injection drug users.
Prevention The goals of prevention are to interrupt the chain of transmission, to protect people at high risk with active immunization through the use of hepatitis B vaccine, and to use passive immunization for unprotected people exposed to HBV. PREVENTING TRANSMISSION Continued screening of blood donors for the presence of hepatitis B antigens will further decrease the risk of transmission by
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blood transfusion. The use of disposable syringes, needles, and lancets and the introduction of needleless IV administration systems reduce the risk of spreading this infection from one patient to another or to health care personnel during the collection of blood samples or the administration of parenteral therapy. Good personal hygiene is fundamental to infection control. In the clinical laboratory, work areas should be disinfected daily. Gloves are worn when handling all blood and body fluids as well as HBAgpositive specimens, or when there is potential exposure to blood (blood drawing) or to patients’ secretions. Eating and smoking are prohibited in the laboratory and in other areas exposed to secretions, blood, or blood products. Patient education regarding the nature of the disease, its infectiousness, and prognosis is a critical factor in preventing transmission and protecting contacts. ACTIVE IMMUNIZATION: HEPATITIS B VACCINE Active immunization is recommended for individuals at high risk for hepatitis B (eg, health care personnel and hemodialysis patients). In addition, individuals with hepatitis C and other chronic liver diseases should receive the vaccine (CDC, 1999). A yeast-recombinant hepatitis B vaccine (Recombivax HB) is used to provide active immunity. Long-term studies of healthy adults and children indicate that immunologic memory remains intact for at least 5 to 10 years, although antibody levels may become low or undetectable. Measurable levels of antibodies may not be essential for protection. In those with normal immune systems, booster doses are not generally required. The CDC (2002) does not recommend booster doses at this time except for hemodialysis patients. The need for booster doses may be revisited if reports of hepatitis B increase or an increased prevalence of the carrier state develops, indicating that protection is declining. A hepatitis B vaccine prepared from plasma of humans chronically infected with HBV is used only rarely and in patients who are immunodeficient or allergic to recombinant yeast-derived vaccines. Both forms of the hepatitis B vaccine are administered intramuscularly in three doses, the second and third doses 1 and 6 months after the first dose. The third dose is very important in producing prolonged immunity. Hepatitis B vaccination should be administered to adults in the deltoid muscle. Antibody response may be measured by anti-HBs levels 1 to 3 months after completing the basic course of vaccine, but this testing is not routine and not currently recommended. Individuals who fail to respond may benefit from one to three additional doses (Koff, 2001). People at high risk, including nurses and other health care personnel exposed to blood or blood products, should receive active immunization. Health care workers who have had frequent contact with blood are screened for anti-HBs to determine whether immunity is already present from previous exposure. The vaccine produces active immunity to HBV in 90% of healthy people (Koff, 2001). It does not provide protection to those already exposed to HBV and provides no protection against other types of viral hepatitis. Side effects of immunization are infrequent; soreness and redness at the injection site are the most common complaints. Because hepatitis B infection is frequently transmitted sexually, hepatitis B vaccination is recommended for all unvaccinated persons being evaluated for a sexually transmitted disease (STD). It is also recommended for those with a history of an STD, persons with multiple sex partners, those who have sex with injection drug users, and sexually active men who have sex with other men (CDC, 2002). Universal childhood vaccination for hepatitis B prevention has been instituted in the United States. Vaccination was initially targeted for select high-risk populations, but the U.S. Public
Health Service and the CDC (1999) have endorsed universal vaccination of all infants. Catch-up vaccination is also recommended for all children and adolescents up to the age of 19 who were not previously immunized. Studies (Chang, 2000; Wu et al., 1999) show that universal vaccination of all newborns in endemic areas has dramatically reduced the carrier rate among children and the incidence of childhood hepatocellular carcinoma. In the United States, studies regarding the effectiveness of the vaccine are ongoing, but it is known that clinical infection is rarely observed during long-term follow-up of known responders (ie, health care workers) who seroconverted within 3 months of the third dose of vaccine (Bircher et al., 1999). Development of chronic carrier states has not been reported in adult responders to the vaccine. PASSIVE IMMUNITY: HEPATITIS B IMMUNE GLOBULIN Hepatitis B immune globulin (HBIG) provides passive immunity to hepatitis B and is indicated for people exposed to HBV who have never had hepatitis B and have never received hepatitis B vaccine. Specific indications for postexposure vaccine with HBIG include: (1) inadvertent exposure to HBAg-positive blood through percutaneous (needlestick) or transmucosal (splashes in contact with mucous membrane) routes, (2) sexual contact with people positive for HBAg, and (3) perinatal exposure (babies born to HBV-infected mothers should receive HBIG within 12 hours of delivery). HBIG, which provides passive immunity, is prepared from plasma selected for high titers of anti-HBs. Prompt immunization with HBIG (within hours to a few days after exposure to hepatitis B) increases the likelihood of protection. Both active and passive immunization are recommended for people exposed to hepatitis B through sexual contact or through percutaneous or transmucosal routes. If HBIG and hepatitis B vaccine are administered at the same time, separate sites and separate syringes should be used. Prophylaxis with high doses of HBIG started at the time of liver transplantation and continued indefinitely improves survival by thwarting recurrence of hepatitis B (Bacon & Di Bisceglie, 2000). There has been no evidence that HIV infection can be transmitted by HBIG. Gerontologic Considerations The elderly patient who contracts hepatitis B has a serious risk of severe liver cell necrosis or fulminant hepatic failure, particularly if other illnesses are present. The patient is seriously ill and the prognosis is poor, so efforts should be undertaken to eliminate other factors (eg, medications, alcohol) that may affect liver function.
Medical Management The goals of treatment are to minimize infectivity, normalize liver inflammation, and decrease symptoms. Of all the agents that have been used to treat chronic type B viral hepatitis, alpha interferon as the single modality of therapy offers the most promise. This regimen of 5 million units daily or 10 million units three times weekly for 4 to 6 months results in remission of disease in approximately one third of patients (Befeler & Di Bisceglie, 2000). The long-term benefits of this treatment are being assessed. Interferon must be administered by injection and has significant side effects, including fever, chills, anorexia, nausea, myalgias, and fatigue. Late side effects are more serious and may necessitate dosage reduction or discontinuation. These include bone marrow suppression, thyroid dysfunction, alopecia, and bacterial infections. Two antiviral agents (lamivudine [Epvir] and adefovir [Hepsera]) oral nucleoside analogs, have been approved for use in
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chronic hepatitis B in the United States. Viral resistance may be an issue with these agents, and studies of their effectiveness alone and in combination with other therapies are ongoing (Befeler & Di Bisceglie, 2000). Bed rest may be recommended, regardless of other treatment, until the symptoms of hepatitis have subsided. Activities are restricted until the hepatic enlargement and elevated levels of serum bilirubin and liver enzymes have disappeared. Gradually increased activity is then allowed. Adequate nutrition should be maintained; proteins are restricted when the liver’s ability to metabolize protein byproducts is impaired, as demonstrated by symptoms. Measures to control the dyspeptic symptoms and general malaise include the use of antacids and antiemetics, but all medications should be avoided if vomiting occurs. If vomiting persists, the patient may require hospitalization and fluid therapy. Because of the mode of transmission, the patient is evaluated for other bloodborne diseases (eg, HIV infection).
Nursing Management Convalescence may be prolonged, with complete symptomatic recovery sometimes requiring 3 to 4 months or longer. During this stage, gradual resumption of physical activity is encouraged after the jaundice has resolved. The nurse identifies psychosocial issues and concerns, particularly the effects of separation from family and friends if the patient is hospitalized during the acute and infective stages. Even if not hospitalized, the patient will be unable to work and must avoid sexual contact. Planning is required to minimize alterations in sensory perception. Planning that includes the family helps to decrease their fears and anxieties about the spread of the disease. PROMOTING HOME AND COMMUNITY-BASED CARE Teaching Patients Self-Care. Because of the prolonged period of convalescence, the patient and family must be prepared for home care. Provision for adequate rest and nutrition must be ensured. The nurse informs family members and friends who have had intimate contact with the patient about the risks of contracting hepatitis B and makes arrangements for them to receive hepatitis B vaccine or hepatitis B immune globulin as prescribed. Those at risk must be aware of the early signs of hepatitis B and of ways to reduce risk to themselves by avoiding all modes of transmission. Patients with all forms of hepatitis should avoid drinking alcohol. Continuing Care. Follow-up visits by a home care nurse may be needed to assess the patient’s progress and answer family members’ questions about disease transmission. A home visit also permits assessment of the patient’s physical and psychological status and the patient and family’s understanding of the importance of adequate rest and nutrition. The nurse also reinforces previous instructions. Because of the risk of transmission through sexual intercourse, strategies to prevent exchange of body fluids are advised, such as abstinence or the use of condoms. The nurse emphasizes the importance of keeping follow-up appointments and participating in other health promotion activities and recommended health screenings.
HEPATITIS C VIRUS (HCV) A significant proportion of cases of viral hepatitis are neither hepatitis A, hepatitis B, nor hepatitis D; as a result, they are classified as hepatitis C (formerly referred to as non-A, non-B hepatitis, or
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NANB hepatitis). Whereas blood transfusions and sexual contact once accounted for most cases of hepatitis C in the United States, other parenteral means, such as sharing contaminated needles by IV/injection drug users and unintentional needlesticks and other injuries in health care workers, now account for a significant number of cases. There are approximately 35,000 new cases of hepatitis C in the United States each year. About 4 million persons (1.8% of the U.S. population) have been infected with HCV, making it the most common chronic blood-borne infection nationally. A fourfold increase in the number of adults diagnosed with HCV is projected from 1990 to 2015. The highest prevalence of hepatitis C is in adults 40 to 59 years of age, and in this age group its prevalance is highest in African Americans. There are 10,000 to 12,000 deaths each year in the United States due to hepatitis C; it has been suggested that these are underestimates. HCV is the underlying cause of about one-third of cases of hepatocellular carcinoma, and it is the most common reason for liver transplantation (NIH Consensus Conference, 2002). Individuals at special risk for hepatitis C include IV/injection drug users, sexually active people with multiple partners, patients receiving frequent transfusions or those who require large volumes of blood, and health care personnel. The incubation period is variable and may range from 15 to 160 days. The clinical course of acute hepatitis C is similar to that of hepatitis B; symptoms are usually mild. A chronic carrier state occurs frequently, however, and there is an increased risk of chronic liver disease, including cirrhosis or liver cancer, after hepatitis C. Small amounts of alcohol taken regularly appear to encourage progression of the disease. Therefore, alcohol and medications that may affect the liver should be avoided (Chart 39-9). There is no benefit from rest, diet, or vitamin supplements. Recent studies have demonstrated that a combination of interferon (Intron-A) and ribavirin (Rebetol), two antiviral agents, is effective in producing improvement in patients with hepatitis C and in treating relapses. Some patients experience complete remission with combination therapy, which is the treatment of choice according to the FDA (Cheney, Chopra & Graham, 2000). Hemolytic anemia, the most frequent side effect, may be severe enough to require discontinuation of treatment. Ribavirin must be used with caution in women of childbearing age. A molecule (polyethylene glycol moiety [PEG]) added to the interferon keeps it in the body longer without reducing its efficacy and extends the dosing interval to once a week. Pegylated interferon (Pegasys) is now available (Lauer & Walker, 2001; Sheffield et al., 2001). Screening of blood has reduced the incidence of hepatitis associated with blood transfusions, and public health programs are helping to reduce the number of cases associated with shared needles in illicit drug use.
Chart 39-9
Risk Factors for Hepatitis C • Recipient of blood products or organ transplant prior to 1992 or clotting factor concentrates before 1987
• Health care and public safety workers after needlestick injuries • • • •
or mucosal exposure to blood Children born to women infected with hepatitis C virus Past/current illicit IV/injection drug use Past treatment with chronic hemodialysis Sex with infected partner, having multiple sex partners, history of STD, unprotected sex
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HEPATITIS D VIRUS (HDV)
TOXIC HEPATITIS
Hepatitis D (delta agent) occurs in some cases of hepatitis B. Because the virus requires hepatitis B surface antigen for its replication, only individuals with hepatitis B are at risk for hepatitis D. Anti-delta antibodies in the presence of HBAg on testing confirm the diagnosis. It is also common among IV/injection drug users, hemodialysis patients, and recipients of multiple blood transfusions. Sexual contact with those with hepatitis B is considered to be an important mode of transmission of hepatitis B and D. The incubation period varies between 21 and 140 days (Bacon & Di Bisceglie, 2000). The symptoms of hepatitis D are similar to those of hepatitis B, except that patients are more likely to develop fulminant hepatitis and to progress to chronic active hepatitis and cirrhosis. Treatment is similar to that of other forms of hepatitis; interferon as a specific treatment for hepatitis D is under investigation.
Toxic hepatitis resembles viral hepatitis in onset. Obtaining a history of exposure to hepatotoxic chemicals, medications, or other agents assists in early treatment and removal of the offending agent. Anorexia, nausea, and vomiting are the usual symptoms; jaundice and hepatomegaly are noted on physical assessment. Symptoms are more intense for the more severely toxic patient. Recovery from acute toxic hepatitis is rapid if the hepatotoxin is identified early and removed or if exposure to the agent has been limited. Recovery is unlikely if there is a prolonged period between exposure and onset of symptoms. There are no effective antidotes. The fever rises; the patient becomes toxic and prostrated. Vomiting may be persistent, with the emesis containing blood. Clotting abnormalities may be severe, and hemorrhages may appear under the skin. The severe GI symptoms may lead to vascular collapse. Delirium, coma, and seizures develop, and within a few days the patient may die of fulminant hepatic failure (discussed below) unless he or she receives a liver transplant. Short of liver transplantation, few treatment options are available. Therapy is directed toward restoring and maintaining fluid and electrolyte balance, blood replacement, and comfort and supportive measures. A few patients recover from acute toxic hepatitis only to develop chronic liver disease. If the liver heals, there may be scarring, followed by postnecrotic cirrhosis.
HEPATITIS E VIRUS (HEV) Hepatitis E is believed to be transmitted by the fecal–oral route, principally through contaminated water in areas with poor sanitation. The incubation period is variable, estimated to range between 15 and 65 days. In general, hepatitis E resembles hepatitis A. It has a self-limiting course with an abrupt onset. Jaundice is nearly always present. Chronic forms do not develop. Avoiding contact with the virus through good hygiene, including hand washing, is the major method of prevention of hepatitis E. The effectiveness of immune globulin in protecting against hepatitis E virus is uncertain.
HEPATITIS G (HGV) AND GB VIRUS-C It has long been believed that there is another non-A, non-B, nonC agent causing hepatitis in humans. The incubation period for post-transfusion hepatitis is 14 to 145 days, too long for hepatitis B or C. In the United States, about 5% of chronic liver disease remains cryptogenic (does not appear to be autoimmune or viral in origin), and half the patients have previously received transfusions. Thus, a new form of hepatitis (hepatitis G or GBV-C) has been described. They are two different isolates of the same virus. Autoantibodies are absent. The clinical significance of this virus remains uncertain. Risk factors are similar to those for hepatitis C. There is no clear relationship between GBV-C/HGV infection and progressive liver disease. Persistent infection does occur but does not affect the clinical course.
Management of Patients With Nonviral Hepatic Disorders Certain chemicals have toxic effects on the liver and when taken by mouth, inhaled, or injected parenterally produce acute liver cell necrosis, or toxic hepatitis. The chemicals most commonly implicated in this disease are carbon tetrachloride, phosphorus, chloroform, and gold compounds. These substances are true hepatotoxins. Many medications may induce hepatitis but are sensitizing rather than toxic. The result, drug-induced hepatitis, is similar to acute viral hepatitis, but parenchymal destruction tends to be more extensive. Some medications that can lead to hepatitis are isoniazid, halothane, acetaminophen, and certain antibiotics, antimetabolites, and anesthetic agents.
DRUG-INDUCED HEPATITIS Drug-induced hepatitis is responsible for 20% to 25% of cases of acute hepatic failure in the United States (Maddrey, Schiff & Sorrell, 2001). Manifestations of sensitivity to a medication may occur on the first day of its use or not until several months later, depending on the medication. Usually the onset is abrupt, with chills, fever, rash, pruritus, arthralgia, anorexia, and nausea. Later, there may be jaundice and dark urine and an enlarged and tender liver. When the offending medication is withdrawn, symptoms may gradually subside. However, reactions may be severe and even fatal, even though the medication is stopped. If fever, rash, or pruritus occurs from any medication, its use should be stopped immediately. Although any medication can affect liver function, use of acetaminophen (found in many over-the counter medications used to treat fever and pain) has been identified as the leading cause of acute liver failure (Ostapowicz, Fontana, Schiodt, et al., 2002). Others commonly associated with liver injury include but are not limited to anesthetic agents, medications used to treat rheumatic and musculoskeletal disease, antidepressants, psychotropic medications, anticonvulsants, and anti-tuberculosis agents. Inhalational agents of the halothane family (halokanes) are metabolized by the liver and excreted in bile. These volatile anesthetics may also decrease hepatic blood flow. Halothane hepatitis is a dreaded but rare complication of halothane administration. Sevoflurane and desflurane may have less hepatotoxic effects than halokanes. Nitrous oxide, an adjunct to halokanes, is not hepatotoxic. Because it undergoes little hepatic metabolism, isoflurane is considered the anesthetic agent of choice in patients with liver disease (Bacon & Di Bisceglie, 2000). Although its efficacy is uncertain, a short course of high-dose corticosteroids may be used in patients with severe hypersensitivity. Liver transplantation is an option for drug-induced hepatitis, but outcomes may not be as successful as with other causes of liver failure.
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FULMINANT HEPATIC FAILURE Fulminant hepatic failure is the clinical syndrome of sudden and severely impaired liver function in a previously healthy person. According to the original and generally accepted definition, fulminant hepatic failure develops within 8 weeks of the first symptoms of jaundice (Maddrey et al., 2001). Patterns of the progression from jaundice to encephalopathy have been identified and have led to proposals of time-based classifications, but no agreement as to these classifications has been reached. However, three categories are frequently cited: hyperacute, acute, and subacute liver failure. In hyperacute liver failure, the duration of jaundice before the onset of encephalopathy is 0 to 7 days; in acute liver failure, it is 8 to 28 days; and in subacute liver failure, it is 28 to 72 days. The prognosis for fulminant hepatic failure is much worse than for chronic liver failure. However, in fulminant failure, the hepatic lesion is potentially reversible, with survival rates of approximately 50% to 85% (survival rates depend greatly on the etiology of liver failure). Those who do not survive die of massive hepatocellular injury and necrosis (Maddrey et al., 2001). Viral hepatitis is a common cause of fulminant hepatic failure; other causes include toxic medications (eg, acetaminophen) and chemicals (eg, carbon tetrachloride), metabolic disturbances (Wilson’s disease, a hereditary syndrome with deposition of copper in the liver), and structural changes (Budd-Chiari syndrome, an obstruction to outflow in major hepatic veins). Jaundice and profound anorexia may be the initial reasons the patient seeks health care. Fulminant hepatic failure is often accompanied by coagulation defects, renal failure and electrolyte disturbances, infection, hypoglycemia, encephalopathy, and cerebral edema.
Management The key to optimizing treatment is rapid recognition of acute liver failure and intensive interventions. Treatment modalities may include plasma exchanges (plasmapheresis) or charcoal hemoperfusion for the removal (theoretically) of potentially harmful metabolites (Kaptanoglu & Blei, 2000); however, more clinical trials are needed to determine their effects or outcomes. Hepatocytes within synthetic fiber columns have been tested as liver support systems (liver assist devices) and a bridge to transplantation. Research into interventions for acute liver failure has begun to focus on techniques that combine the efficacy of a whole liver with the convenience and biocompatibility of hemodialysis. The acronyms ELAD (extracorporeal liver assist devices) and BAL (bioartificial liver) have been used to describe these hybrid devices. These temporary devices help patients to survive until transplantation is possible. The BAL exposes separated plasma to a cartridge containing porcine liver cells after the plasma has flowed through a charcoal column that removes substances toxic to hepatocytes. The ELAD device exposes whole blood to cartridges containing human hepatoblastoma cells, resulting in removal of toxic substances. Similar extracorporeal circuits using xenografts will likely be studied in the near future (Maddrey et al., 2001). Although these approaches appear promising, controlled studies are required. There is a high risk for cerebral edema, a life-threatening complication, in patients with fulminant liver failure with stage 4 encephalopathy. The cause is not fully understood, although disruption of the blood–brain barrier and plasma leaking into the cerebrospinal fluid has been proposed as one theory (Sherlock & Dooley, 2002). These patients require intracranial pressure monitoring. Measures to promote adequate cerebral perfusion include
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careful fluid balance and hemodynamic assessments, a quiet environment, and diuresis with mannitol, an osmotic diuretic. To prevent surges in intracranial pressure related to agitation, barbiturate anesthesia or pharmacologic paralysis and sedation are indicated. Other support measures include monitoring for and treating hypoglycemia, coagulopathies, and infection. Despite these treatment modalities, the mortality rate remains high. Consequently, liver transplantation (discussed later in this chapter) has become the treatment of choice for fulminant hepatic failure.
HEPATIC CIRRHOSIS Cirrhosis is a chronic disease characterized by replacement of normal liver tissue with diffuse fibrosis that disrupts the structure and function of the liver. There are three types of cirrhosis or scarring of the liver:
• Alcoholic cirrhosis, in which the scar tissue characteristi-
• •
cally surrounds the portal areas. This is most frequently due to chronic alcoholism and is the most common type of cirrhosis. Postnecrotic cirrhosis, in which there are broad bands of scar tissue as a late result of a previous bout of acute viral hepatitis. Biliary cirrhosis, in which scarring occurs in the liver around the bile ducts. This type usually is the result of chronic biliary obstruction and infection (cholangitis); it is much less common than the other two types.
The portion of the liver chiefly involved in cirrhosis consists of the portal and the periportal spaces, where the bile canaliculi of each lobule communicate to form the liver bile ducts. These areas become the sites of inflammation, and the bile ducts become occluded with inspissated (thickened) bile and pus. The liver attempts to form new bile channels; hence, there is an overgrowth of tissue made up largely of disconnected, newly formed bile ducts and surrounded by scar tissue. Clinical manifestations include intermittent jaundice and fever. Initially the liver is enlarged, hard, and irregular, but eventually it atrophies.
Pathophysiology Although several factors have been implicated in the etiology of cirrhosis, alcohol consumption is considered the major causative factor. Cirrhosis occurs with greatest frequency among alcoholics. Although nutritional deficiency with reduced protein intake contributes to liver destruction in cirrhosis, excessive alcohol intake is the major causative factor in fatty liver and its consequences. Cirrhosis, however, has also occurred in people who do not consume alcohol and in those who consume a normal diet and have a high alcohol intake. Some people appear to be more susceptible than others to this disease, whether or not they are alcoholics or malnourished. Other factors may play a role, including exposure to certain chemicals (carbon tetrachloride, chlorinated naphthalene, arsenic, or phosphorus) or infectious schistosomiasis. Twice as many men as women are affected, although women are at greater risk of developing alcohol-induced liver disease for an as yet undiscovered reason. Most patients are between 40 and 60 years of age. Each year more than 25,000 people die of chronic liver diseases and cirrhosis in the United States (NIDDK, 2000). Alcoholic cirrhosis is characterized by episodes of necrosis involving the liver cells, sometimes occurring repeatedly throughout
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the course of the disease. The destroyed liver cells are replaced gradually by scar tissue; eventually the amount of scar tissue exceeds that of the functioning liver tissue. Islands of residual normal tissue and regenerating liver tissue may project from the constricted areas, giving the cirrhotic liver its characteristic hobnail appearance. The disease usually has an insidious onset and a protracted course, occasionally proceeding over a period of 30 or more years. The prognosis of different forms of cirrhosis caused by various liver diseases has been investigated in several studies. Of the many prognostic indicators, the Child’s classification seems most useful in predicting the outcome of patients with liver disease (Table 39-5). It is also used in choosing management approaches.
Clinical Manifestations Signs and symptoms of cirrhosis increase in severity as the disease progresses. The severity of the manifestations helps to categorize the disorder into two main presentations (Chart 39-10). Compensated cirrhosis, with its less severe, often vague symptoms, may be discovered secondarily at a routine physical examination. The hallmarks of decompensated cirrhosis result from failure of the liver to synthesize proteins, clotting factors, and other substances and manifestations of portal hypertension (see the “Hepatic Dysfunction” section of this chapter for clinical manifestations and management of portal hypertension, ascites, varices, and hepatic encephalopathy). LIVER ENLARGEMENT Early in the course of cirrhosis, the liver tends to be large and its cells loaded with fat. The liver is firm and has a sharp edge noticeable on palpation. Abdominal pain may be present because of recent, rapid enlargement of the liver, producing tension on the fibrous covering of the liver (Glisson’s capsule). Later in the disease, the liver decreases in size as scar tissue contracts the liver tissue. The liver edge, if palpable, is nodular. PORTAL OBSTRUCTION AND ASCITES These late manifestations are due partly to chronic failure of liver function and partly to obstruction of the portal circulation. Practically all the blood from the digestive organs is collected in the portal veins and carried to the liver. Because a cirrhotic liver does not allow the blood free passage, it backs up into the spleen and the GI tract and these organs become the seat of chronic passive congestion; that is, they are stagnant with blood and thus cannot function properly. Indigestion and altered bowel function result. Fluid rich in protein may accumulate in the peritoneal cavity, producing ascites. This can be demonstrated through percussion for shifting dullness or a fluid wave (see Fig. 39-5).
Chart 39-10
• ASSESSMENT
Clinical Manifestations of Cirrhosis Compensated Intermittent mild fever Vascular spiders Palmar erythema (reddened palms) Unexplained epistaxis Ankle edema Vague morning indigestion Flatulent dyspepsia Abdominal pain Firm, enlarged liver Splenomegaly Decompensated Ascites Jaundice Weakness Muscle wasting Weight loss Continuous mild fever Clubbing of fingers Purpura (due to decreased platelet count) Spontaneous bruising Epistaxis Hypotension Sparse body hair White nails Gonadal atrophy
INFECTION AND PERITONITIS Bacterial peritonitis may develop in cirrhotic patients with ascites in the absence of an intra-abdominal source of infection or an abscess. This condition is referred to as spontaneous bacterial peritonitis. Bacteremia is believed to be the most likely route of infection. Clinical signs may be absent; paracentesis may be necessary for diagnosis. Antibiotic therapy is effective in the treatment and prevention of recurrent episodes of spontaneous bacterial peritonitis. GASTROINTESTINAL VARICES The obstruction to blood flow through the liver resulting from the fibrotic changes also results in the formation of collateral blood vessels in the GI system and shunting of blood from the portal vessels into blood vessels with lower pressures. As a result, the patient with cirrhosis often has prominent, distended abdominal blood vessels, which are visible on abdominal inspection (caput medusae), and
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Assessment and Management of Patients With Hepatic Disorders
distended blood vessels throughout the GI tract. The esophagus, stomach, and lower rectum are common sites of collateral blood vessels. These distended blood vessels form varices or hemorrhoids, depending on their location (see Fig. 39-6). Because these vessels were not intended to carry the high pressure and volume of blood imposed by cirrhosis, they may rupture and bleed. Therefore, assessment must include observation for occult and frank bleeding from the GI tract. Approximately 25% of patients develop minor hematemesis; others have profuse hemorrhage from gastric and esophageal varices (Bacon & Di Bisceglie, 2000). EDEMA Another late symptom of cirrhosis is edema, which is attributed to chronic liver failure. A reduced plasma albumin concentration predisposes the patient to the formation of edema. Edema is generalized but often affects lower extremities, upper extremities, and the presacral area. Facial edema is not typical. Overproduction of aldosterone occurs, causing sodium and water retention and potassium excretion. VITAMIN DEFICIENCY AND ANEMIA Because of inadequate formation, use, and storage of certain vitamins (notably vitamins A, C, and K), signs of their deficiency are common, particularly hemorrhagic phenomena associated with vitamin K deficiency. Chronic gastritis and impaired GI function, together with inadequate dietary intake and impaired liver function, account for the anemia often associated with cirrhosis. The anemia and the patient’s poor nutritional status and poor state of health result in severe fatigue, which interferes with the ability to carry out routine daily activities. MENTAL DETERIORATION Additional clinical manifestations include deterioration of mental function with impending hepatic encephalopathy and hepatic coma. Neurologic assessment is indicated and includes the patient’s general behavior, cognitive abilities, orientation to time and place, and speech patterns.
Assessment and Diagnostic Findings The extent of liver disease and the type of treatment are determined after reviewing the laboratory findings. Because the functions of the liver are complex, there are many diagnostic tests that may provide information about liver function (see Table 39-1). The patient needs to know why these tests are being performed and ways to cooperate. In severe parenchymal liver dysfunction, the serum albumin level tends to decrease and the serum globulin level rises. Enzyme tests indicate liver cell damage: serum alkaline phosphatase, AST, ALT, and GGT levels increase, and the serum cholinesterase level may decrease. Bilirubin tests are performed to measure bile excretion or bile retention; elevated levels can occur with cirrhosis and other liver disorders. Prothrombin time is prolonged. Ultrasound scanning is used to measure the difference in density of parenchymal cells and scar tissue. CT, MRI, and radioisotope liver scans give information about liver size and hepatic blood flow and obstruction. Diagnosis is confirmed by liver biopsy. Arterial blood gas analysis may reveal a ventilation– perfusion imbalance and hypoxia.
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Medical Management The management of the patient with cirrhosis is usually based on the presenting symptoms. For example, antacids are prescribed to decrease gastric distress and minimize the possibility of GI bleeding. Vitamins and nutritional supplements promote healing of damaged liver cells and improve the general nutritional status. Potassium-sparing diuretics (spironolactone [Aldactone], triamterene [Dyrenium]) may be indicated to decrease ascites, if present; these diuretics are preferable to other diuretic agents because they minimize the fluid and electrolyte changes common with other agents. An adequate diet and avoidance of alcohol are essential. Although the fibrosis of the cirrhotic liver cannot be reversed, its progression may be halted or slowed by such measures. Preliminary studies indicate that colchicine, an antiinflammatory agent used to treat the symptoms of gout, may increase the length of survival in patients with mild to moderate cirrhosis. Improved survival has been observed in patients with alcoholic cirrhosis. Colchicine is believed to reverse the fibrotic processes in cirrhosis, and this has improved survival (Bacon & Di Bisceglie, 2000).
NURSING PROCESS: THE PATIENT WITH HEPATIC CIRRHOSIS Assessment Nursing assessment focuses on the onset of symptoms and the history of precipitating factors, particularly long-term alcohol abuse, as well as dietary intake and changes in the patient’s physical and mental status. The patient’s past and current patterns of alcohol use (duration and amount) are assessed and documented. It is also important to document any exposure to toxic agents encountered in the workplace or during recreational activities. The nurse documents and reports exposure to potentially hepatotoxic substances (medications, illicit IV/injection drugs, inhalants) or general anesthetic agents. The nurse assesses the patient’s mental status through the interview and other interactions with the patient; orientation to person, place, and time is noted. The patient’s ability to carry out a job or household activities provides some information about physical and mental status. The patient’s relationships with family, friends, and coworkers may give some indication about incapacitation secondary to alcohol abuse and cirrhosis. Abdominal distention and bloating, GI bleeding, bruising, and weight changes are noted. The nurse assesses nutritional status, which is of major importance in cirrhosis, by daily weights and monitoring of plasma proteins, transferrin, and creatinine levels.
Diagnosis NURSING DIAGNOSES Based on all the assessment data, the patient’s major nursing diagnoses may include the following:
• Activity intolerance related to fatigue, general debility, muscle wasting, and discomfort
• Imbalanced nutrition, less than body requirements, related to chronic gastritis, decreased GI motility, and anorexia
• Impaired skin integrity related to compromised immunologic status, edema, and poor nutrition
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• Risk for injury and bleeding related to altered clotting mechanisms
COLLABORATIVE PROBLEMS/ POTENTIAL COMPLICATIONS Based on assessment data, potential complications may include:
• Bleeding and hemorrhage • Hepatic encephalopathy • Fluid volume excess Planning and Goals The goals for the patient may include increased participation in activities, improvement of nutritional status, improvement of skin integrity, decreased potential for injury, improvement of mental status, and absence of complications.
Nursing Interventions PROMOTING REST The patient with active liver disease requires rest and other supportive measures to permit the liver to reestablish its functional ability. If the patient is hospitalized, weight and fluid intake and output are measured and recorded daily. The nurse adjusts the patient’s position in bed for maximal respiratory efficiency, which is especially important if ascites is marked because it interferes with adequate thoracic excursion. Oxygen therapy may be required in liver failure to oxygenate the damaged cells and prevent further cell destruction. Rest reduces the demands on the liver and increases the liver’s blood supply. Because the patient is susceptible to the hazards of immobility, efforts to prevent respiratory, circulatory, and vascular disturbances are initiated. These measures may help prevent such problems as pneumonia, thrombophlebitis, and pressure ulcers. When nutritional status improves and strength increases, the nurse encourages the patient to increase activity gradually. Activity and mild exercise, as well as rest, are planned. IMPROVING NUTRITIONAL STATUS The patient with cirrhosis who has no ascites or edema and exhibits no signs of impending hepatic coma should receive a nutritious, high-protein diet if tolerated, supplemented by vitamins of the B complex and others as indicated (including vitamins A, C, K and folic acid). Because proper nutrition is so important, the nurse makes every effort to encourage the patient to eat. This is as important as any medication. Often small, frequent meals are tolerated better than three large meals because of the abdominal pressure exerted by ascites. Protein supplements may also be indicated. Patient preferences are considered. Patients with prolonged or severe anorexia, or those who are vomiting or eating poorly for any reason, may receive nutrients enterally or parenteral nutrition. Patients with fatty stools (steatorrhea) should receive watersoluble forms of fat-soluble vitamins—A, D, and E (Aquasol A, D, and E). Folic acid and iron are prescribed to prevent anemia. If the patient shows signs of impending or advancing coma, the amount of protein in the diet is decreased temporarily. In the absence of hepatic encephalopathy, a moderate-protein, high-calorie intake is provided, with protein foods of high biologic value. A diet containing 1 to 1.5 g of protein per kilogram of body weight per day is required unless the patient is malnourished. Protein is restricted
if encephalopathy develops. Incorporating vegetable protein to meet protein needs may decrease the risk of encephalopathy. Sodium restriction is also indicated to prevent ascites. A high-calorie intake should be maintained, and supplemental vitamins and minerals should be provided (eg, oral potassium if the serum potassium level is normal or low and if renal function is normal). PROVIDING SKIN CARE Providing careful skin care is important because of subcutaneous edema, the patient’s immobility, jaundice, and increased susceptibility to skin breakdown and infection. Frequent position changes are necessary to prevent pressure ulcers. It is important to avoid irritating soaps and the use of adhesive tape to prevent trauma to the skin. Lotion may be soothing to irritated skin; the nurse takes measures to minimize scratching by the patient. REDUCING RISK OF INJURY The nurse protects the patient with cirrhosis from falls and other injuries. The side rails should be in place and padded with blankets in case the patient becomes agitated or restless. To minimize agitation, the nurse orients the patient to time and place and explains all procedures. The nurse instructs the patient to ask for assistance to get out of bed. The nurse carefully evaluates any injury because of the possibility of internal bleeding. Because of the risk for bleeding from abnormal clotting, the patient should use an electric rather than a safety razor. A soft-bristled toothbrush will help to minimize bleeding gums, and pressure applied to all venipuncture sites will help to minimize bleeding. MONITORING AND MANAGING POTENTIAL COMPLICATIONS Bleeding and Hemorrhage The patient is at increased risk for bleeding and hemorrhage because of decreased production of prothrombin and decreased ability of the diseased liver to synthesize the substances necessary for blood coagulation. Precautionary measures include protecting the patient with padded side rails, applying pressure to injection sites, and avoiding injury from sharp objects. The nurse observes for melena and assesses stools for blood (signs of possible internal bleeding). Vital signs are monitored regularly. Precautions are taken to minimize rupture of esophageal varices by avoiding further increases in portal pressure (discussed previously). Dietary modification and appropriate use of stool softeners may help prevent straining during defecation. The nurse closely monitors the patient for GI bleeding and keeps readily available equipment (Sengstaken–Blakemore tube), IV fluids, and medications needed to treat hemorrhage from esophageal and gastric varices. If hemorrhage occurs, the nurse assists the physician in initiating measures to halt the bleeding, administering fluid and blood component therapy and medications. The patient with massive hemorrhage from bleeding esophageal or gastric varices may be transferred to the intensive care unit and may require emergency surgery or other treatment modalities. The patient and family require explanations about the event and the necessary treatment. Hepatic Encephalopathy Hepatic encephalopathy and coma, possible complications of cirrhosis, may present as deteriorating mental status and dementia as well as physical signs such as abnormal voluntary and involuntary movements. Hepatic encephalopathy is mainly caused by the ac-
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cumulation of ammonia in the blood and its effect on cerebral metabolism. Many factors predispose the patient with cirrhosis to hepatic encephalopathy; therefore, the patient may require extensive diagnostic testing to identify hidden sources of bleeding and ammonia. Treatment may include the use of lactulose and nonabsorbable intestinal tract antibiotics to decrease ammonia levels, modification in medications to eliminate those that may precipitate or worsen hepatic encephalopathy, and bed rest to minimize energy expenditure. Monitoring is an essential nursing function to identify early deterioration in mental status. The nurse monitors the patient’s mental status closely and reports changes so that treatment of encephalopathy can be initiated promptly. Because electrolyte disturbances can contribute to encephalopathy, serum electrolyte levels are carefully monitored and corrected if abnormal. Oxygen is administered if oxygen desaturation occurs. The nurse monitors for fever or abdominal pain, which may signal the onset of bacterial peritonitis or other infection (see the discussion of hepatic encephalopathy in the “Hepatic Dysfunction” section of this Chapter).
Recovery is neither rapid nor easy; there are frequent setbacks and apparent lack of improvement. Many patients find it difficult to refrain from using alcohol for comfort or escape. The nurse has a significant role in offering support and encouragement to this patient.
Fluid Volume Excess Patients with advanced chronic liver disease develop cardiovascular abnormalities. These occur due to an increased cardiac output and decreased peripheral vascular resistance, possibly resulting from the release of vasodilators. A hyperdynamic circulatory state develops in patients with cirrhosis, and plasma volume increases. This increase in circulating plasma volume may be due in part to splanchnic venous congestion (Bircher et al., 1999). The greater the degree of hepatic decompensation, the more severe the hyperdynamic state. Close assessment of the cardiovascular and respiratory status is key for the nurse caring for patients with this disorder. Pulmonary compromise is always a potential complication of endstage liver disease due to plasma volume excess, making prevention of pulmonary complications an important role for the nurse. Administering diuretics, implementing fluid restrictions, and enhancing patient positioning can optimize pulmonary function. Fluid retention may be noted in the development of ascites and lower extremity swelling and dyspnea. Monitoring intake and output, daily weight changes, changes in abdominal girth, and edema formation is part of nursing assessment in the hospital or in the home setting. Patients are also monitored for nocturia and, later, oliguria as these states indicate increasing severity of liver function (Bacon & Di Bisceglie, 2000).
EXPECTED PATIENT OUTCOMES Expected patient outcomes may include:
PROMOTING HOME AND COMMUNITY-BASED CARE Teaching Patients Self-Care During the patient’s hospital stay, the nurse and other health care providers prepare the patient with cirrhosis for discharge, focusing on dietary instruction. Of greatest importance is the exclusion of alcohol from the diet. The patient may need referral to Alcoholics Anonymous, psychiatric care, or counseling or may benefit from support from a spiritual advisor. Sodium restriction will continue for a considerable time, if not permanently. The patient will require written instructions, teaching, reinforcement, and support from the staff as well as the family members. The success of treatment depends on convincing the patient of the need to adhere completely to the therapeutic plan. This includes rest, lifestyle changes, adequate dietary intake, and the elimination of alcohol. The nurse also instructs the patient and family about the symptoms of impending encephalopathy, possible bleeding tendencies, and susceptibility to infection.
Continuing Care Referral of the patient for home care may assist the patient in dealing with the transition from hospital to home, where the use of alcohol may have been an important part of normal home and social life. The home care nurse assesses the patient’s progress at home and the manner in which the patient and family cope with the elimination of alcohol and the dietary restrictions. The nurse also reinforces previous teaching and answers questions that may not have occurred to the patient or family until the patient is back home and trying to establish new patterns of eating, drinking, and lifestyle. For an overall view of the nursing management of the patient with impaired liver function, refer to the Plan of Nursing Care.
Evaluation
1. Participates in activities a. Plans activities and exercises to allow alternating periods of rest and activity b. Reports increased strength and well-being c. Participates in hygiene care 2. Increases nutritional intake a. Demonstrates intake of appropriate nutrients and avoidance of alcohol as reflected by diet log b. Gains weight without increased edema and ascites formation c. Reports decrease in GI disturbances and anorexia d. Identifies foods and fluids that are nutritious and allowed on diet or restricted from diet e. Adheres to vitamin therapy regimen f. Describes the rationale for small, frequent meals 3. Exhibits improved skin integrity a. Has intact skin without evidence of breakdown, infection, or trauma b. Demonstrates normal turgor of skin of extremities and trunk, without edema c. Changes position frequently and inspects bony prominences daily d. Uses lotions to decrease pruritus 4. Avoids injury a. Is free of ecchymotic areas or hematoma formation b. States rationale for side rails and asks for assistance to get out of bed c. Uses measures to prevent trauma (eg, uses electric razor and soft toothbrush, blows nose gently, arranges furniture to prevent bumps and falls, avoids straining during defecation) 5. Is free of complications a. Reports absence of frank bleeding from GI tract (ie, absence of melena and hematemesis) b. Is oriented to time, place, and person and demonstrates normal attention span c. Has serum ammonia level within normal limits d. Identifies early, reportable signs of impaired thought processes (text continues on page 1113)
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METABOLIC AND ENDOCRINE FUNCTION
Plan of Nursing Care The Patient With Impaired Liver Function Nursing Interventions
Rationale
Expected Outcomes
Nursing Diagnosis: Activity intolerance related to fatigue, lethargy, and malaise Goal: Patient reports decrease in fatigue and reports increased ability to participate in activities 1. Assess level of activity tolerance and degree of fatigue, lethargy, and malaise when performing routine ADLs. 2. Assist with activities and hygiene when fatigued. 3. Encourage rest when fatigued or when abdominal pain or discomfort occurs. 4. Assist with selection and pacing of desired activities and exercise. 5. Provide diet high in carbohydrates with protein intake consistent with liver function. 6. Administer supplemental vitamins (A, B complex, C, and K).
1. Provides baseline for further assessment and criteria for assessment of effectiveness of interventions 2. Promotes exercise and hygiene within patient’s level of tolerance 3. Conserves energy and protects the liver
• Exhibits increased interest in activities and
4. Stimulates patient’s interest in selected activities 5. Provides calories for energy and protein for healing
• Plans activities to allow ample periods of rest • Takes vitamins as prescribed
events
• Participates in activities and gradually increases exercise within physical limits
• Reports increased strength and well-being • Reports absence of abdominal pain and discomfort
6. Provides additional nutrients
Nursing Diagnosis: Imbalanced nutrition: less than body requirements, related to abdominal distention and discomfort and anorexia Goal: Positive nitrogen balance, no further loss of muscle mass; meets nutritional requirements 1. Assess dietary intake and nutritional status through diet history and diary, daily weight measurements and laboratory data. 2. Provide diet high in carbohydrates with protein intake consistent with liver function. 3. Assist patient in identifying low-sodium foods. 4. Elevate the head of the bed during meals.
5. Provide oral hygiene before meals and pleasant environment for meals at meal time. 6. Offer smaller, more frequent meals (6 per day). 7. Encourage patient to eat meals and supplementary feedings. 8. Provide attractive meals and an aesthetically pleasing setting at meal time. 9. Eliminate alcohol. 10. Apply an ice collar for nausea. 11. Administer medications prescribed for nausea, vomiting, diarrhea, or constipation. 12. Encourage increased fluid intake and exercise if the patient reports constipation.
1. Identifies deficits in nutritional intake and adequacy of nutritional state 2. Provides calories for energy, sparing protein for healing
• Exhibits improved nutritional status by in• •
3. Reduces edema and ascites formation 4. Reduces discomfort from abdominal distention and decreases sense of fullness produced by pressure of abdominal contents and ascites on the stomach 5. Promotes positive environment and increased appetite; reduces unpleasant taste 6. Decreases feeling of fullness, bloating 7. Encouragement is essential for the patient with anorexia and gastrointestinal discomfort. 8. Promotes appetite and sense of well-being 9. Eliminates “empty calories” and further damage from alcohol 10. May reduce incidence of nausea 11. Reduces gastrointestinal symptoms and discomforts that decrease the appetite and interest in food 12. Promotes normal bowel pattern and reduces abdominal discomfort and distention
• • • • • • • • • •
creased weight (without fluid retention) and improved laboratory data. States rationale for dietary modifications Identifies foods high in carbohydrates and within protein requirements (moderate to high protein in cirrhosis and hepatitis, low protein in hepatic failure) Reports improved appetite Participates in oral hygiene measures Reports increased appetite; identifies rationale for smaller, frequent meals Demonstrates intake of high-calorie diet; adheres to protein restriction Identifies foods and fluids that are nutritious and permitted on diet Gains weight without increased edema or ascites formation Reports increased appetite and well-being Excludes alcohol from diet Takes medications for gastrointestinal disorders as prescribed Reports normal gastrointestinal function with regular bowel function
(continued)
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Plan of Nursing Care The Patient With Impaired Liver Function (Continued) Nursing Interventions
Rationale
Expected Outcomes
Nursing Diagnosis: Impaired skin integrity related to pruritus from jaundice and edema Goal: Decrease potential for pressure ulcer development; breaks in skin integrity 1. Assess degree of discomfort related to pruritus and edema. 2. Note and record degree of jaundice and extent of edema. 3. Keep patient’s fingernails short and smooth. 4. Provide frequent skin care; avoid use of soaps and alcohol-based lotions. 5. Massage every 2 hours with emollients; turn every 2 hours 6. Initiate use of alternating-pressure mattress or low air loss bed. 7. Recommend avoiding use of harsh detergents. 8. Assess skin integrity every 4–8 hours. Instruct patient and family in this activity. 9. Restrict sodium as prescribed. 10. Perform range of motion exercises every 4 hours; elevate edematous extremities whenever possible.
1. Assists in determining appropriate interventions 2. Provides baseline for detecting changes and evaluating effectiveness of interventions 3. Prevents skin excoriation and infection from scratching 4. Removes waste products on skin while preventing dryness of skin 5. Promotes mobilization of edema 6. Minimizes prolonged pressure on bony prominences susceptible to breakdown 7. May decrease skin irritation and need for scratching 8. Edematous skin and tissue has compromised nutrient supply and is vulnerable to pressure and trauma 9. Minimizes edema formation 10. Promotes mobilization of edema
• Exhibits intact skin without redness, excoriation, or breakdown
• Reports relief from pruritus • Exhibits no skin excoriation from scratching • Uses nondrying soaps and lotions. States • • •
rationale for use of nondrying soaps and lotions. Turns self periodically. Exhibits reduced edema of dependent parts of the body. Exhibits no areas of skin breakdown Exhibits decreased edema; normal skin turgor
Nursing Diagnosis: High risk for injury related to altered clotting mechanisms and altered level of consciousness Goal: Reduced risk of injury 1. Assess level of consciousness and cognitive level. 2. Provide safe environment (pad side rails, remove obstacles in room, prevent falls). 3. Provide frequent surveillance to orient patient and avoid use of restraints. 4. Replace sharp objects (razors) with safer items. 5. Observe each stool for color, consistency, and amount. 6. Be alert for symptoms of anxiety, epigastric fullness, weakness, and restlessness. 7. Test each stool and emesis for occult blood. 8. Observe for hemorrhagic manifestations: ecchymosis, epistaxis, petechiae, and bleeding gums. 9. Record vital signs at frequent intervals, depending on patient acuity (every 1–4 hours). 10. Keep patient quiet and limit activity. 11. Assist physician in passage of tube for esophageal balloon tamponade, if its insertion is indicated.
1. Assists in determining patient’s ability to protect self and comply with required self-protective actions; may detect deterioration of hepatic function 2. Minimizes falls and injury if falls occur
• Is oriented to time, place, and person • Exhibits no hallucinations, and demon-
3. Protects patient from harm while stimulating and orienting patient; use of restraints may disturb patient further 4. Avoids cuts and bleeding
•
5. Permits detection of bleeding in gastrointestinal tract 6. May indicate early signs of bleeding and shock 7. Detects early evidence of bleeding
•
• • • •
8. Indicates altered clotting mechanisms
• •
9. Provides baseline and evidence of hypovolemia, and hemorrhagic shock
•
10. Minimizes risk of bleeding and straining 11. Promotes nontraumatic insertion of tube in anxious and combative patient for immediate treatment of bleeding
•
• •
strates no efforts to get up unassisted or to leave hospital Exhibits no ecchymoses (bruises), cuts, or hematoma Uses electric razor rather than sharp-edged razor Exhibits absence of frank bleeding from gastrointestinal tract Exhibits absence of restlessness, epigastric fullness, and other indicators of hemorrhage and shock Exhibits negative results of test for occult gastrointestinal bleeding Is free of ecchymotic areas or hematoma formation Exhibits normal vital signs Maintains rest and remains quiet if active bleeding occurs Identifies rationale for blood transfusions and measures to treat bleeding Uses measures to prevent trauma (eg, uses soft toothbrush, blows nose gently, avoids bumps and falls, avoids straining during defecation) Experiences no side effects of medications Takes all medications as prescribed (continued)
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METABOLIC AND ENDOCRINE FUNCTION
Plan of Nursing Care The Patient With Impaired Liver Function (Continued) Nursing Interventions
Rationale
Expected Outcomes
12. Observe during blood transfusions.
12. Permits detection of transfusion reactions (risk is increased with multiple blood transfusions needed for active bleeding from esophageal varices) 13. Assists in evaluating extent of bleeding and blood loss 14. Reduces risk of aspiration of gastric contents and minimizes risk of further trauma to esophagus and stomach by preventing vomiting 15. Promotes clotting by providing fatsoluble vitamin necessary for clotting. 16. Reassures anxious patient and permits monitoring and detection of further needs of the patient 17. Minimizes risk of further bleeding by promoting vasoconstriction of esophageal and gastric blood vessels 18. Promotes safety of patient a. Minimizes risk of trauma and bleeding by avoiding falls and cuts, etc. b. Reduces risk of nosebleed (epistaxis) secondary to trauma and decreased clotting c. Prevents trauma to oral mucosa while promoting good oral hygiene d. Promotes healing
• Identifies rationale for precautions with
13. Measure and record nature, time, and amount of vomitus. 14. Maintain patient in fasting state, if indicated. 15. Administer vitamin K as prescribed. 16. Remain with patient during episodes of bleeding. 17. Offer cold liquids by mouth when bleeding stops (if prescribed). 18. Institute measures to prevent trauma: a. Maintain safe environment. b. Encourage gentle blowing of nose. c. Provide soft toothbrush and avoid use of toothpicks. d. Encourage intake of foods with high content of vitamin C. e. Apply cold compresses where indicated. f. Record location of bleeding sites. g. Use small-gauge needles for injections. 19. Administer medications carefully; monitor for side effects.
use of all medications
• Cooperates with treatment modalities
e. Minimizes bleeding into tissues by promoting local vasoconstriction f. Permits detection of new bleeding sites and monitoring of previous sites of bleeding g. Minimizes oozing and blood loss from repeated injections 19. Reduces risk of side effects secondary to damaged liver’s inability to detoxify (metabolize) medications normally
Nursing Diagnosis: Disturbed body image related to changes in appearance, sexual dysfunction, and role function Goal: Patient verbalizes feelings consistent with improvement of body image and self-esteem 1. Assess changes in appearance and the meaning these changes have for patient and family. 2. Encourage patient to verbalize reactions and feelings about these changes. 3. Assess patient’s and family’s previous coping strategies. 4. Assist and encourage patient to maximize appearance and explore alternatives to previous sexual and role functions.
1. Provides information for assessing impact of changes in appearance, sexual function, and role on the patient and family 2. Enables patient to identify and express concerns; encourages patient and significant others to share these concerns 3. Permits encouragement of those coping strategies that are familiar to patient and have been effective in the past 4. Encourages patient to continue safe roles and functions while encouraging exploration of alternatives
• Verbalizes concerns related to changes in appearance, life, and lifestyle
• Shares concerns with significant others • Identifies past coping strategies that have been effective
• Uses past effective coping strategies to • • •
deal with changes in appearance, life, and lifestyle Maintains good grooming and hygiene Identifies short-term goals and strategies to achieve them Exercises an active role in decision making about self and care
(continued)
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Plan of Nursing Care The Patient With Impaired Liver Function (Continued) Nursing Interventions
Rationale
Expected Outcomes
5. Assist patient in identifying short-term goals. 6. Encourage and assist patient in decision making about care. 7. Identify with patient resources to provide additional support (counselor, spiritual advisor). 8. Assist patient in identifying previous practices that may have been harmful to self (alcohol and drug abuse).
5. Accomplishing these goals serves as positive reinforcement and increases self-esteem. 6. Promotes patient’s control of life and improves sense of well-being and self-esteem 7. Assists patient in identifying resources and accepting assistance from others when indicated 8. Recognition and acknowledgment of the harmful effects of these practices are necessary for identifying a healthier lifestyle.
• Identifies resources that are not harmful • Verbalizes that some of previous lifestyle practices have been harmful
• Uses healthy expressions of frustration, anger, anxiety
Nursing Diagnosis: Chronic pain and discomfort related to enlarged tender liver and ascites Goal: Increased level of comfort 1. Maintain bed rest when patient experiences abdominal discomfort. 2. Administer antispasmodic and sedative agents as prescribed. 3. Observe, record, and report presence and character of pain and discomfort. 4. Reduce sodium and fluid intake if prescribed. 5. Prepare patient and assist with paracentesis.
1. Reduces metabolic demands and protects the liver 2. Reduces irritability of the gastrointestinal tract and decreases abdominal pain and discomfort 3. Provides baseline to detect further deterioration of status and to evaluate interventions 4. Minimizes further formation of ascites 5. Removal of ascites fluid may decrease abdominal discomfort
• Reports pain and discomfort if present • Maintains bed rest and decreases activity in presence of pain
• Takes antispasmodic and sedatives as indicated and as prescribed
• Reports decreased pain and abdominal discomfort
• Reduces sodium and fluid intake to prescribed levels if indicated to treat ascites
• Exhibits decreased abdominal girth and appropriate weight changes
• Reports decreased discomfort after paracentesis
Nursing Diagnosis: Fluid volume excess related to ascites and edema formation Goal: Restoration of normal fluid volume 1. Restrict sodium and fluid intake if prescribed. 2. Administer diuretics, potassium, and protein supplements as prescribed. 3. Record intake and output every 1 to 8 hours depending on response to interventions and on patient acuity. 4. Measure and record abdominal girth and weight daily. 5. Explain rationale for sodium and fluid restriction. 6. Prepare patient and assist with paracentesis.
1. Minimizes formation of ascites and edema
• Consumes diet low in sodium and within
2. Promotes excretion of fluid through the kidneys and maintenance of normal fluid and electrolyte balance 3. Indicates effectiveness of treatment and adequacy of fluid intake
• Takes diuretics, potassium, and protein
prescribed fluid restriction
4. Monitors changes in ascites formation and fluid accumulation 5. Promotes patient’s understanding of restriction and cooperation with it 6. Paracentesis will temporarily decrease amount of ascites present.
• • • • •
supplements as indicated without experiencing side effects Exhibits increased urine output Exhibits decreasing abdominal girth Exhibits no rapid increase in weight Identifies rationale for sodium and fluid restriction Shows a decrease in ascites with decreased weight
(continued)
Unit 8
1110
METABOLIC AND ENDOCRINE FUNCTION
Plan of Nursing Care The Patient With Impaired Liver Function (Continued) Nursing Interventions
Rationale
Expected Outcomes
Nursing Diagnosis: Disturbed thought processes related to deterioration of liver function and increased serum ammonia level Goal: Improved mental status; safety maintained 1. Restrict dietary protein as prescribed. 2. Give frequent, small feedings of carbohydrates. 3. Protect from infection. 4. Keep environment warm and draft-free. 5. Pad the side rails of the bed. 6. Limit visitors. 7. Provide careful nursing surveillance to ensure patient’s safety. 8. Avoid opioids and barbiturates.
9. Awaken at intervals (every 2–4 hours) to assess cognitive status.
1. Reduces source of ammonia (protein foods) 2. Promotes consumption of adequate carbohydrates for energy requirements and spares protein from breakdown for energy 3. Minimizes risk for further increase in metabolic requirements 4. Minimizes shivering, which would increase metabolic requirements 5. Provides protection for the patient should hepatic coma and seizure activity occur 6. Minimizes patient’s activity and metabolic requirements 7. Provides close monitoring of new symptoms and minimizes trauma to the confused patient 8. Prevents masking of symptoms of hepatic coma and prevents drug overdose secondary to reduced ability of the damaged liver to metabolize opioids and barbiturates 9. Provides stimulation to the patient and opportunity for observing the patient’s level of consciousness
• Adheres to protein restriction • Demonstrates an interest in events and activities in environment
• Demonstrates normal attention span • Follows and participates in conversation • • • •
appropriately Is oriented to person, place, and time Remains in bed when indicated Reports no urinary or fecal incontinence Experiences no seizures
Nursing Diagnosis: Risk for imbalanced body temperature: hyperthermia related to inflammatory process of cirrhosis or hepatitis Goal: Maintenance of normal body temperature, free from infection 1. Record temperature regularly (every 4 hours). 2. Encourage fluid intake. 3. Apply cool sponges or icebag for elevated temperature. 4. Administer antibiotics as prescribed. 5. Avoid exposure to infections. 6. Keep patient at rest while temperature is elevated. 7. Assess for abdominal pain, tenderness.
1. Provides baseline to detect fever and to evaluate interventions 2. Corrects fluid loss from perspiration and fever and increases patient’s level of comfort 3. Promotes reduction of fever and increases patient’s comfort 4. Ensures appropriate serum concentration of antibiotics to treat infection 5. Minimizes risk of further infection and further increases in body temperature and metabolic rate 6. Reduces metabolic rate
• Exhibits normal temperature and reports absence of chills or sweating
• Demonstrates adequate intake of fluids • Exhibits no evidence of local or systemic infection
7. May occur with bacterial peritonitis
(continued)
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Assessment and Management of Patients With Hepatic Disorders
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Plan of Nursing Care The Patient With Impaired Liver Function (Continued) Nursing Interventions
Rationale
Expected Outcomes
Nursing Diagnosis: Ineffective breathing pattern related to ascites and restriction of thoracic excursion secondary to ascites, abdominal distention, and fluid in the thoracic cavity Goal: Improved respiratory status 1. Elevate head of bed to at least 30 degrees. 2. Conserve patient’s strength by providing rest periods and assisting with activities. 3. Change position every 2 hours. 4. Assist with paracentesis or thoracentesis. a. Explain procedure and its purpose to patient. b. Have patient void before paracentesis. c. Support and maintain position during procedure. d. Record both the amount and the character of fluid aspirated. e. Observe for evidence of coughing, increasing dyspnea, or pulse rate.
1. Reduces abdominal pressure on the diaphragm and permits fuller thoracic excursion and lung expansion 2. Reduces metabolic and oxygen requirements 3. Promotes expansion and oxygenation of all areas of the lungs 4. Paracentesis and thoracentesis (performed to remove fluid from the abdominal and thoracic cavities, respectively) may be frightening to the patient. a. Helps obtain patient’s cooperation with procedures b. Prevents inadvertent bladder injury c. Prevents inadvertent organ or tissue injury d. Provides record of fluid removed and indication of severity of limitation of lung expansion by fluid e. Indicates irritation of the pleural space and evidence of pneumothorax or hemothorax.
• Experiences improved respiratory status • Reports decreased shortness of breath • Reports increased strength and sense of well-being
• Exhibits normal respiratory rate
(12–18/min) with no adventitious sounds
• Exhibits full thoracic excursion without shallow respirations
• Exhibits normal arterial blood gases • Exhibits adequate oxygen saturation by pulse oximetry
• Experiences absence of confusion or cyanosis
Collaborative Problem: Gastrointestinal bleeding and hemorrhage Goal: The patient will develop no episodes of gastrointestinal bleeding and hemorrhage 1. Assess patient for evidence of gastrointestinal bleeding or hemorrhage. If bleeding does occur: a. Monitor vital signs (blood pressure, pulse, respiratory rate) every 4 hours or more frequently, depending on acuity. b. Assess skin temperature, level of consciousness every 4 hours or more frequently, depending on acuity. c. Monitor gastrointestinal secretions and output (emesis, stool for occult or obvious bleeding). Test emesis for blood once per shift and with any change. Hematest each stool. d. Monitor hematocrit and hemoglobin for trends and changes. 2. Avoid activities that increase intraabdominal pressure (straining, turning). a. Avoid coughing/sneezing. b. Assist patient to turn. c. Keep all needed items within easy reach. d. Use measures to prevent constipation such as adequate fluid intake; stool softeners. e. Ensure small meals.
1. Allows early detection of signs and symptoms of bleeding and hemorrhage
• Experiences no episodes of bleeding and hemorrhage
• Vital signs are within acceptable range for patient
• No evidence of bleeding from gastrointestinal tract
• Hematocrit and hemoglobin levels within acceptable limits
• Turns and moves without straining and increasing intra-abdominal pressure
• No straining with bowel movements • No further bleeding episodes if aggressive • 2. Minimizes increases in intra-abdominal pressure that could lead to rupture and bleeding of esophageal or gastric varices
• •
treatment of bleeding and hemorrhage was needed Patient and family state rationale for treatments Patient and family identify supports available to them Patient and family describe signs and symptoms of a recurrent bleeding episode and identify needed action
(continued)
Plan of Nursing Care The Patient With Impaired Liver Function (Continued) Nursing Interventions
Rationale
3. Have equipment (Blakemore tube, medications, intravenous fluids) available if indicated.
3. Equipment, medications, and supplies will be readily available if patient experiences bleeding from ruptured esophageal or gastric varices. 4. Gastrointestinal bleeding and hemorrhage require emergency measures (eg, insertion of Blakemore tube, administration of fluids and medications). 5. The patient is at high risk for respiratory complications, including asphyxiation if gastric balloon of Blakemore tube ruptures or migrates upward. 6. The patient who experiences hemorrhage is very anxious and fearful; minimizing anxiety assists in control of hemorrhage. 7. Risk of rebleeding is high with all treatment modalities used to halt gastrointestinal bleeding. 8. Family members are likely to be anxious about the patient’s status; providing information will reduce their anxiety level and promote more effective coping. 9. Risk of rebleeding is high. Subtle signs may be more quickly identified.
4. Assist with procedures and therapy needed to treat gastrointestinal bleeding and hemorrhage. 5. Monitor respiratory status every hour and minimize risk of respiratory complications if esophageal tamponade is needed. 6. Prepare patient physically and psychologically for other treatment modalities if needed. 7. Monitor patient for recurrence of bleeding and hemorrhage. 8. Keep family informed of patient’s status.
9. Once recovered from bleeding episode, provide patient and family with information regarding signs and symptoms of gastrointestinal bleeding.
Expected Outcomes
Collaborative Problem: Hepatic encephalopathy Goal: Patient will be maintained safely and without injury 1. Assess cognitive status every 4–8 hours: a. Assess patient’s orientation to person, place, and time. b. Monitor patient’s level of activity, restlessness, and agitation. Assess for presence of flapping hand tremors (asterixis). c. Obtain and record daily sample of patient’s handwriting or ability to construct a simple figure (eg, star). d. Assess neurologic signs (deep tendon reflexes, ability to follow instructions). 2. Monitor medications to prevent administration of those that may precipitate hepatic encephalopathy (sedatives, hypnotics, analgesics). 3. Monitor laboratory data, especially serum ammonia level. 4. Notify physician of even subtle changes in patient’s neurologic status and cognitive function. 5. Limit sources of protein from diet if indicated. 6. Administer medications prescribed to reduce serum ammonia level (eg, lactulose, antibiotics, glucose, benzodiazepine antagonist [Flumazanil] if indicated). 7. Assess respiratory status and initiate measures to prevent complications. 8. Protect patient’s skin and tissue from pressure and breakdown. 1112
1. Data will provide baseline of patient’s cognitive status and enable detection of changes.
• Remains awake, alert, and aware of surroundings
• Is oriented to time, place, and person • Exhibits no restlessness or agitation • Record of handwriting demonstrates no deterioration in cognitive function
• States rationale for treatment used to prevent or treat hepatic encephalopathy
• Demonstrates stable serum ammonia level within acceptable limits
2. Medications are a common precipitating factor in development of hepatic encephalopathy in patients at risk. 3. Increases in serum ammonia level are associated with hepatic encephalopathy and coma. 4. Allows early initiation of treatment of hepatic encephalopathy and prevention of hepatic coma 5. Reduces breakdown and conversion of protein to ammonia 6. Reduces serum ammonia level
7. The patient who develops hepatic coma is at risk for respiratory complications (ie, pneumonia, atelectasis, infection). 8. The patient in coma is at risk for skin breakdown and pressure ulcer formation.
• Consumes adequate caloric intake and adheres to protein restriction
• Takes medications as prescribed • Breath sounds are normal without adventitious sounds
• Skin and tissue intact without evidence of pressure or breaks in integrity
Chapter 39
Assessment and Management of Patients With Hepatic Disorders
Cancer of the Liver Hepatic tumors may be malignant or benign. Benign liver tumors were uncommon until the widespread use of oral contraceptives. With the use of oral contraceptives, benign tumors of the liver occur most frequently in women in their reproductive years.
PRIMARY LIVER TUMORS Few cancers originate in the liver. Primary liver tumors usually are associated with chronic liver disease, hepatitis B and C infections, and cirrhosis. Hepatocellular carcinoma (HCC) is by far the most common type of primary liver cancer, but it is rare in the United States (Bacon & Di Bisceglie, 2000). HCC is usually nonresectable because of rapid growth and metastasis. Other types of primary liver cancer include cholangiocellular carcinoma and combined hepatocellular and cholangiocellular carcinoma. If found early, resection may be possible, but early detection is unlikely. Cirrhosis, chronic infection with hepatitis B and C, and exposure to certain chemical toxins (eg, vinyl chloride, arsenic) have been implicated as causes of HCC. Cigarette smoking has also been identified as a risk factor, especially when combined with alcohol use. Some evidence suggests that aflatoxin, a metabolite of the fungus Aspergillus flavus, may be a risk factor for HCC. This is especially true in areas where HCC is endemic (ie, Asia and Africa). Aflatoxin and other similar toxic molds can contaminate food such as ground nuts and grains and may act as a co-carcinogen with hepatitis B. The risk of contamination is greatest when these foods are stored unrefrigerated in tropical or subtropical climates.
LIVER METASTASES Metastases from other primary sites are found in the liver in about half of all advanced cancer cases (Bacon & Di Bisceglie, 2000). Malignant tumors are likely to reach the liver eventually, by way of the portal system or lymphatic channels, or by direct extension from an abdominal tumor. Moreover, the liver apparently is an ideal place for these malignant cells to thrive. Often the first evidence of cancer in an abdominal organ is the appearance of liver metastases; unless exploratory surgery or an autopsy is performed, the primary tumor may never be identified.
Clinical Manifestations The early manifestations of malignancy of the liver include pain, a continuous dull ache in the right upper quadrant, epigastrium, or back. Weight loss, loss of strength, anorexia, and anemia may also occur. The liver may be enlarged and irregular on palpation. Jaundice is present only if the larger bile ducts are occluded by the pressure of malignant nodules in the hilum of the liver. Ascites develops if such nodules obstruct the portal veins or if tumor tissue is seeded in the peritoneal cavity.
Assessment and Diagnostic Findings The liver cancer diagnosis is based on clinical signs and symptoms, the history and physical examination, and the results of laboratory and x-ray studies. Increased serum levels of bilirubin, alkaline phosphatase, AST, GGT, and lactic dehydrogenase may occur. Leukocytosis (increased white blood cells), erythrocytosis (increased red blood cells), hypercalcemia, hypoglycemia, and hypocholesterolemia may also be seen on laboratory assessment.
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The serum level of alpha-fetoprotein (AFP), which serves as a tumor marker, is elevated in 30% to 40% of patients with primary liver cancer. Levels of carcinoembryonic antigen (CEA), a marker of advanced cancer of the digestive tract, may be elevated. These two markers together are useful to distinguish between metastatic liver disease and primary liver cancer. Many patients have metastases from the primary liver tumor to other sites by the time diagnosis is made; metastases occur primarily to the lung but may also occur to regional lymph nodes, adrenals, bone, kidneys, heart, pancreas, and stomach. X-rays, liver scans, CT scans, ultrasound studies, MRI, arteriography, and laparoscopy may be part of the diagnostic workup and may be performed to determine the extent of the cancer. Positive emission tomograms (PET scans) are used to evaluate a wide range of metastatic tumors of the liver. Confirmation of a tumor’s histology can be made by biopsy under imaging guidance (CT scan or ultrasound) or laparoscopically. Local or systemic dissemination of the tumor by needle biopsy or fine-needle biopsy can occur but is rare. Some clinicians believe that these procedures should not be performed if the tumor is thought to be resectable; rather, for primary HCC diagnosis should be confirmed by frozen section at the time of laparotomy.
Medical Management Although surgical resection of the liver tumor is possible in some patients, the underlying cirrhosis, so prevalent in cancer of the liver, increases the risks associated with surgery. Radiation therapy and chemotherapy have been used in treating cancer of the liver with varying degrees of success. Although these therapies may prolong survival and improve quality of life by reducing pain and discomfort, their major effect is palliative. RADIATION THERAPY The use of external beam radiation for the treatment of liver tumors has been limited by the radiosensitivity of normal hepatocytes. Doses over 2,500 to 3,000 cGy may result in radiation hepatitis (O’Grady et al., 2000). More effective methods of delivering radiation to tumors of the liver include (1) intravenous or intraarterial injection of antibodies that are tagged with radioactive isotopes and specifically attack tumor-associated antigens and (2) percutaneous placement of a high-intensity source for interstitial radiation therapy (delivering radiation directly to the tumor cells). CHEMOTHERAPY Chemotherapy has been used to improve quality of life and prolong survival; it also may be used as adjuvant therapy after surgical resection of hepatic tumors. Systemic chemotherapy and regional infusion chemotherapy are two methods used to administer antineoplastic agents to patients with primary and metastatic hepatic tumors (O’Grady et al., 2000). An implantable pump has been used to deliver a high concentration of chemotherapy to the liver through the hepatic artery. This method provides a reliable, controlled, and continuous infusion of medication that can be carried out in the patient’s home. Recent studies have begun to show some effective palliation and modestly improved survival rates (Bacon & Di Bisceglie, 2000). PERCUTANEOUS BILIARY DRAINAGE Percutaneous biliary or transhepatic drainage is used to bypass biliary ducts obstructed by liver, pancreatic, or bile duct tumors
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in patients with inoperable tumors or in those considered poor surgical risks. Under fluoroscopy, a catheter is inserted through the abdominal wall and past the obstruction into the duodenum. Such procedures are used to reestablish biliary drainage, relieve pressure and pain from the buildup of bile behind the obstruction, and decrease pruritus and jaundice. As a result, the patient is made more comfortable and quality of life and survival are improved. For several days after its insertion, the catheter is opened to external drainage. The bile is observed closely for amount, color, and presence of blood and debris. Complications of percutaneous biliary drainage include sepsis, leakage of bile, hemorrhage, and reobstruction of the biliary system by debris in the catheter or from encroaching tumor. Therefore, the patient is observed for fever and chills, bile drainage around the catheter, changes in vital signs, and evidence of biliary obstruction, including increased pain or pressure, pruritus, and recurrence of jaundice. OTHER NONSURGICAL TREATMENTS Laser hyperthermia has been used to treat hepatic metastases. Heat has been directed to tumors through several methods to cause necrosis of the tumor cells while sparing normal tissue. In radiofrequency thermal ablation, a needle electrode is inserted into the liver tumor under imaging guidance. Radiofrequency energy passes through to the noninsulated needle tip, causing heat and tumor cell death from coagulation necrosis. Immunotherapy is another treatment modality under investigation. In this therapy, lymphocytes with antitumor reactivity are administered to the patient with hepatic cancer. Regression of the tumor, the desired outcome, has been demonstrated in patients with metastatic cancer in whom standard treatment has failed. Transcatheter arterial embolization interrupts the arterial blood flow to small tumors by injecting small particulate embolic or chemotherapeutic agents into the artery supplying the tumor. Ischemia and necrosis of the tumor occur as a result. For multiple small lesions, ultrasound-guided injection of alcohol promotes dehydration of tumor cells and tumor necrosis (Habib, 2000; O’Grady et al., 2000). SURGICAL MANAGEMENT Surgical resection is the treatment of choice when HCC is confined to one lobe of the liver and the function of the remaining liver is considered adequate for postoperative recovery. In the case of metastasis, hepatic resection can be performed when the primary site can be completely excised and the metastasis is limited. Metastases to the liver, however, are rarely limited or solitary. Capitalizing on the regenerative capacity of the liver cells, some surgeons have successfully removed 90% of the liver. However, the presence of cirrhosis limits the ability of the liver to regenerate. Staging of liver tumors aids in predicting the likelihood of surgical cure. A staging system for liver tumors is summarized in Chart 39-11. In preparation for surgery, the patient’s nutritional, fluid, and general physical status is assessed and efforts are undertaken to ensure the best physical condition possible. Support, explanation, and encouragement are provided to help the patient prepare psychologically for the surgery. Extensive diagnostic studies may be performed. Specific studies may include liver scan, liver biopsy, cholangiography, selective hepatic angiography, percutaneous needle biopsy, peritoneoscopy, laparoscopy, ultrasound, CT scans, MRI, and blood tests, particularly determinations of serum alkaline phosphatase, AST, and GGT and its isoenzymes.
Lobectomy. Removal of a lobe of the liver is the most common surgical procedure for excising a liver tumor. If it is necessary to restrict blood flow from the hepatic artery and portal vein beyond 15 minutes, it is likely that hypothermia will be used. For a rightliver lobectomy or an extended right lobectomy (including the medial left lobe), a thoracoabdominal incision is used. An extensive abdominal incision is made for a left lobectomy. Cryosurgery. In cryosurgery (cryoablation), tumors are destroyed by liquid nitrogen at −196° C. To destroy the diseased tissue, two or three freeze-and-thaw cycles are administered via probes during open laparotomy. This technique has been used alone or as an adjunct to hepatic resection in HCC and colorectal metastases not amenable to radical surgical excision. The efficacy of cryosurgery is still being evaluated; indications and outcomes require further investigation. Liver Transplantation. Removing the liver and replacing it with a healthy donor organ is another way to treat liver cancer. Recurrence of the primary liver malignancy after transplantation, however, has been reported to occur in 70% to 85% of cases, and the survival time after recurrence is brief. Metastasis and recurrence may be enhanced by the immunosuppressive therapy needed to prevent rejection. The patient with small tumors may have a good prognosis after transplantation, but recurrence is common with tumors greater than 8 cm in diameter or those that are multifocal or have vascular invasion (Bacon & Di Bisceglie, 2000). See the discussion of liver transplantation that follows.
Chapter 39
Assessment and Management of Patients With Hepatic Disorders
Nursing Management If the patient has had surgery to treat liver cancer, potential problems related to cardiopulmonary involvement include vascular complications and respiratory and liver dysfunction. Metabolic abnormalities require careful attention. A constant infusion of 10% glucose may be required in the first 48 hours to prevent a precipitous fall in the blood glucose level resulting from decreased gluconeogenesis. Because extensive blood loss may occur as well, the patient will receive infusions of blood and IV fluids. The patient requires constant, close monitoring and care for the first 2 or 3 days, similar to postsurgical abdominal and thoracic nursing care. The patient undergoing cryosurgery is monitored closely for hypothermia, hemorrhage, or bile leak; myoglobinuria can occur as a result of tissue necrosis and is minimized by hydration, diuresis, and at times medications (allopurinol) to bind to and aid in the excretion of toxic products. If the patient will receive chemotherapy or radiation therapy in an effort to relieve symptoms, he or she may be discharged home while still receiving one or both of these therapies. The patient may also go home with a biliary drainage system in place. The need for teaching is great because of the need for the patient to participate in care and the family’s role in care at home. PROMOTING HOME AND COMMUNITY-BASED CARE Teaching Patients Self-Care. The nurse instructs the patient to recognize and report the complications and side effects of the chemotherapy that may occur and the actions and desired and undesirable effects of the specific chemotherapy regimen. The nurse also emphasizes the importance of follow-up visits to assess the patient and the tumor’s response to chemotherapy and radiation therapy. If the patient is receiving chemotherapy on an outpatient basis, the nurse explains the patient’s and family’s role in managing the chemotherapy infusion and in assessing the infusion/insertion site. The nurse encourages the patient to resume routine activities as soon as possible, while cautioning him or her to avoid activities that may damage the infusion pump or site. The family and the patient at home with a biliary drainage system in place typically fear that the catheter will be dislodged. They need reassurance and instruction to reduce their fear that the catheter will fall out easily. The patient and family also require instruction on catheter care. They need to learn how to keep the catheter site clean and dry and how to assess the catheter and its insertion site. Irrigation of the catheter with sterile normal saline solution or water may be prescribed to keep the catheter patent and free of debris. The patient and caregivers are taught proper technique to avoid introducing bacteria into the biliary system or catheter during irrigation. They are instructed not to aspirate or draw back on the syringe during irrigation to prevent entry of irritating duodenal contents into the biliary tree or catheter. The patient and caregivers are also instructed about the signs of complications and are encouraged to notify the nurse or physician if problems or questions arise. Continuing Care. In many cases, referral for home care enables the patient with liver cancer to be at home in a familiar environment with family and friends. Because of the poor prognosis associated with liver cancer, the home care nurse serves a vital role in assisting the patient and family to cope with the symptoms that may occur and the prognosis. The home care nurse assesses the
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patient’s physical and psychological status, the adequacy of pain relief, nutritional status, and the presence of symptoms indicating complications of treatment or progression of disease. During home visits, the nurse assesses the function of the chemotherapy pump, the infusion site, and the biliary drainage system, if indicated. The nurse collaborates with the other members of the health care team, the patient, and the family to ensure effective pain management and to manage other problems that may occur: weakness, pruritus, inadequate dietary intake, jaundice, and symptoms associated with metastasis to other sites. The home care nurse also assists the patient and family in making decisions about hospice care and assists with initiation of referrals. The patient is encouraged to discuss preferences for end-of-life care with family members and health care providers (see Chap. 17).
Liver Transplantation Liver transplantation is used to treat life-threatening, end-stage liver disease for which no other form of treatment is available. The transplantation procedure involves total removal of the diseased liver and its replacement with a healthy liver in the same anatomic location (orthotopic liver transplantation [OLT]). Removal of the liver leaves a space for the new liver and permits anatomic reconstruction of the hepatic vasculature and biliary tract as close to normal as possible. The success of liver transplantation depends on successful immunosuppression. Immunosuppressants currently in use include cyclosporine (Neoral), corticosteroids, azathioprine (Imuran), mycophenolate mofetil (CellCept), OKT3 (a monoclonal antibody), tacrolimus (FK506, Prograf), sirolimus (formerly known as rapamycin [Rapamune]), and antithymocyte globulin. Studies are underway to find the most effective combination of immunosuppressive agents and to identify new agents with fewer side effects (Hebert et al., 1999; Watson, Friend & Jamieson, 1999). Despite the success of immunosuppression in reducing the incidence of rejection of transplanted organs, liver transplantation is not a routine procedure and may be accompanied by complications related to the lengthy surgical procedure, immunosuppressive therapy, infection, and the technical difficulties encountered in reconstructing the blood vessels and biliary tract. Long-standing systemic problems resulting from the primary liver disease may complicate the preoperative and postoperative course. Previous surgery of the abdomen, including procedures to treat complications of advanced liver disease (ie, shunt procedures used to treat portal hypertension and esophageal varices) increase the complexity of the transplantation procedure. The indications for liver transplantation are not as limited today as they were when the procedure was first introduced, due to advances in immunosuppressive therapy, improvements in biliary tract reconstruction, and in some cases the use of venovenous bypass. General indications for liver transplantation include irreversible advanced chronic liver disease, fulminant hepatic failure, metabolic liver diseases, and some hepatic malignancies. Examples of disorders that are indications for liver transplantation include hepatocellular liver disease (eg, viral hepatitis, drug- and alcohol-induced liver disease, and Wilson’s disease) and cholestatic diseases (primary biliary cirrhosis, sclerosing cholangitis, and biliary atresia). The patient being considered for liver transplantation frequently has many systemic problems that influence preoperative and postoperative care. Because transplantation is more
Unit 8
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difficult when the patient has developed severe GI bleeding and hepatic coma, efforts are made to perform the procedure before this stage. Liver transplantation is now recognized as an established therapeutic modality rather than an experimental procedure to treat these disorders. As a result, the number of centers where liver transplantation is performed is increasing. Patients requiring transplantation are often referred from distant hospitals to these sites. To prepare the patient and family for liver transplantation, nurses in all settings must understand the processes and procedures of liver transplantation.
SURGICAL PROCEDURE The donor liver is freed from other structures, the bile is flushed from the gallbladder to prevent damage to the walls of the biliary tract, and the liver is perfused with a preservative and
cooled. Before the donor liver is placed in the recipient, it is flushed with cold lactated Ringer’s solution to remove potassium and air bubbles. Anastomoses (connections) of the blood vessels and bile duct are performed between the donor liver and the recipient liver. Biliary reconstruction is performed with an end-to-end anastomosis of the donor and recipient common bile ducts; a stented T-tube is inserted for external drainage of bile. If an end-to-end anastomosis is not possible because of diseased or absent bile ducts, an end-toside anastomosis is made between the common bile duct of the graft and a loop (Roux-en-Y portion) of jejunum (Fig. 39-15A); in this case, bile drainage will be internal and a T-tube will not be inserted (Maddrey et al., 2001). Figure 39-15B and C illustrates the final appearance of the grafted liver and final closure and drain placement. Liver transplantation is a long surgical procedure, partly because the patient with liver failure often has portal hypertension
Portal vein (donor)
Common bile duct (donor)
Cystic duct Common bile duct
Common bile duct (recipient) Tip of the jejunal Roux-en-Y loop
Hepatic artery (recipient) Portal vein (recipient)
Enterotomy for the choledochojejunostomy
A
Hepatic artery (donor)
B
Duodenal drainage tube (T-tube)
Closed suction drainage tubes
C
FIGURE 39-15A–C (A) Roux-en-Y hepatojejunostomy. (B) Final appearance of implanted liver graft. (C) Final closure and drain placement after liver transplant.
Chapter 39
Assessment and Management of Patients With Hepatic Disorders
and subsequently many venous collateral vessels that must be ligated. Blood loss during the surgical procedure may be extensive. If the patient has adhesions from previous abdominal surgery, lysis of adhesions is often necessary. If a shunt procedure was performed previously, it must be surgically reversed to permit adequate portal venous blood supply to the new liver. During the lengthy surgery, providing regular updates to the family about the progress of the operation and the patient’s status is helpful.
COMPLICATIONS The postoperative complication rate is high, primarily because of technical complications or infection. Immediate postoperative complications may include bleeding, infection, and rejection. Disruption, infection, or obstruction of the biliary anastomosis and impaired biliary drainage may occur. Vascular thrombosis and stenosis are other potential complications.
Bleeding Bleeding is common in the postoperative period and may result from coagulopathy, portal hypertension, and fibrinolysis caused by ischemic injury to the donor liver. Hypotension may occur in this phase secondary to blood loss. Administration of platelets, fresh-frozen plasma, and other blood products may be necessary. Hypertension is more common, but its cause is uncertain. Blood pressure elevation that is significant or sustained is treated.
Infection Infection is the leading cause of death after liver transplantation. Pulmonary and fungal infections are common; susceptibility to infection is increased by the immunosuppression needed to prevent rejection (Maddrey et al., 2001). Therefore, precautions must be taken to prevent nosocomial infections by strict asepsis when manipulating arterial lines and urine, bile, and other drainage systems; obtaining specimens; and changing dressings. Meticulous hand hygiene is crucial.
Rejection Rejection is a key concern. A transplanted liver is perceived by the immune system as a foreign antigen. This triggers an immune response, leading to the activation of T lymphocytes that attack and destroy the transplanted liver. Immunosuppressive agents are used long term to prevent this response and rejection of the transplanted liver. These agents inhibit the activation of immunocompetent T lymphocytes to prevent the production of effector T cells. Although the 1- and 5-year survival rates have increased dramatically with the use of new immunosuppressive therapies, these advances are not without major side effects. A major side effect of cyclosporine, which is widely used in transplantation, is nephrotoxicity; this problem seems to be dose-related, and renal dysfunction can be reversed if the dose of cyclosporine is appropriately decreased or if its use is not initiated immediately. Cyclosporine-related side effects have caused many centers to use tacrolimus as first-line therapy because of its efficacy and lower side effect profile. Corticosteroids, azathioprine, mycophenolate mofetil, rapamycin, antithymocyte globulin, and OKT3 are also elements of the various regimens of immunosuppression and may be used as
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the initial therapy to prevent rejection, or later to treat rejection. Liver biopsy and ultrasound may be required to evaluate suspected episodes of rejection. Retransplantation is usually attempted if the transplanted liver fails, but the success rate of retransplantation does not approach that of initial transplantation.
Nursing Management The patient considering transplantation and the family have difficult decisions to make about treatment, use of financial resources, and relocation to another area to be closer to the medical center. They also must cope with the patient’s long-standing health problems and perhaps social and family problems associated with behaviors that may be responsible for the patient’s liver failure. Therefore, the time during which the patient and family are considering liver transplantation and awaiting the news that a liver is available is often stressful. The nurse must be aware of these issues and attuned to the emotional and psychological status of the patient and family. Referral of the patient and family to a psychiatric liaison nurse, psychologist, psychiatrist, or spiritual advisor may be helpful to them as they deal with the stressors associated with end-stage liver disease and liver transplantation. PREOPERATIVE NURSING INTERVENTIONS If irreversible, severe liver dysfunction has been diagnosed, the patient may be a candidate for transplantation. An extensive diagnostic evaluation will be carried out to determine whether the patient is a candidate. The nurse and other health care team members provide the patient and family with full explanations about the procedure, the chances of success, and the risks, including the side effects of long-term immunosuppression. The need for close follow-up and lifelong compliance with the therapeutic regimen, including immunosuppression, is explained to the patient and family. Once accepted as a candidate, the patient is placed on a waiting list at the transplant center and patient information is entered into the United Network for Organ Sharing (UNOS) computer system so that candidates may be matched with appropriate organs as they become available. Unless the patient is having a segmental liver transplantation from a living donor (Chart 39-12), a liver becomes available for transplantation only with the death of another individual, who is usually healthy except for severe brain injury and brain death. Thus, the patient and family undergo a stressful waiting period, and the nurse is often the major source of support. The patient must be accessible at all times in case an appropriate liver becomes available. During this time, liver function may deteriorate further and the patient may experience other complications from the primary liver disease. Because of the current shortage of donor organs, many patients die awaiting transplantation. Malnutrition, massive ascites, and fluid and electrolyte disturbances are treated before surgery to increase the chance of a successful outcome. If the patient’s liver dysfunction has a very rapid onset, as in fulminant hepatic failure, there is little time or opportunity for the patient to consider and weigh options and their consequences; often this patient is in a coma, and the decision to proceed with transplantation is made by the family. The nurse coordinator is an integral member of the transplant team and plays an important role in preparing the patient for liver transplantation. The nurse serves as a patient and family advocate and assumes the important role of link between the patient and the
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Chart 39-12
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METABOLIC AND ENDOCRINE FUNCTION
Innovative Strategies in Liver Transplantation
Segmental liver transplantation in adults using part of the liver of a living donor is a relatively new technique (Bacon & Di Bisceglie, 2000) that poses ethical and medical questions. Issues Related to Donation There are two key issues in donor selection: • The living donor of the liver segment must be a volunteer, without coercion and without financial incentives. • The potential donor must be assessed for medical conditions that would increase his or her risk, since segmental liver transplantation poses serious risks to the donor (Maddrey et al., 2001). Other issues concern risks, benefits, and education of the donor and recipient. An acceptable level of risk and benefits must exist for the potential recipient. In addition, a satisfactory process for educating both the donor and recipient and the family (or families in the case of unrelated parties) should be in place. Informed consent for the donor must also be ensured (Maddrey et al., 2001). Nurse’s Role During the period of evaluation and planning for the elective procedure, nurses are involved in supporting and educating both parties. Addressing the concerns each may have for the other’s welfare requires a multidisciplinary approach of all transplant team members.
other members of the transplant team. The nurse also serves as a resource to other nurses and health care team members involved in evaluating and caring for the patient. POSTOPERATIVE NURSING INTERVENTIONS The patient is maintained in an environment as free from bacteria, viruses, and fungi as possible, because immunosuppressive medications reduce the body’s natural defenses. In the immediate postoperative period, cardiovascular, pulmonary, renal, neurologic, and metabolic functions are monitored continuously. Mean arterial and pulmonary artery pressures are monitored continuously. Cardiac output, central venous pressure, pulmonary capillary wedge pressure, arterial and mixed venous blood gases, oxygen saturation, oxygen demand and delivery, urine output, heart rate, and blood pressure are used to evaluate the patient’s hemodynamic status and intravascular fluid volume. Liver function tests, electrolyte levels, the coagulation profile, chest x-ray, electrocardiogram, and fluid output, including urine, bile, and drainage from Jackson-Pratt tubes, are monitored closely. Because the liver is responsible for the storage of glycogen and the synthesis of protein and clotting factors, these substances need to be monitored and replaced in the immediate postoperative period. Because of the likelihood of atelectasis and an altered ventilation–perfusion ratio as a result of the insult to the diaphragm during the surgical procedure, prolonged anesthesia, immobility, and postoperative pain, the patient will have an endotracheal tube in place and will require mechanical ventilation during the initial postoperative period. Suctioning is performed as required and sterile humidification is provided. As the vital signs and condition stabilize, efforts are made to assist the patient to recover from the trauma of this complex surgery. After removal of the endotracheal tube, the nurse encourages the patient to use an incentive spirometer to decrease the risk for atelectasis. Once the arterial lines and the urinary catheter are removed, the patient is assisted to get out of bed, to ambulate
as tolerated, and to participate in self-care to prevent the complications associated with immobility. Close monitoring for signs and symptoms of liver dysfunction and rejection will continue throughout the hospital stay. Plans will be made for close followup after discharge as well. Teaching, initiated during the preoperative period, continues after surgery. PROMOTING HOME AND COMMUNITY-BASED CARE Teaching Patients Self-Care. Teaching the patient and family about long-term measures to promote health is crucial for success of the transplant and represents an important role of the nurse. The patient and family must understand why they should adhere continuously to the therapeutic regimen, with special emphasis on the methods of administration, rationale, and side effects of the prescribed immunosuppressive agents. The nurse provides written as well as verbal instructions about how and when to take the medications. To avoid running out of medication or skipping a dose, the patient must make sure that an adequate supply of medication is available. Instructions are also provided about the signs and symptoms that indicate problems that require consultation with the transplant team. The patient with a T-tube in place must be taught how to manage the tube. Continuing Care. The nurse emphasizes the importance of follow-up blood tests and visits to the transplant team. Trough blood levels of immunosuppressive agents are obtained, along with other blood tests that assess the function of the liver and kidneys. During the first months, the patient is likely to require blood tests two or three times a week. As the patient’s condition stabilizes, blood studies and visits to the transplant team are less frequent. The importance of routine ophthalmologic examinations is emphasized because of the increased incidence of cataracts and glaucoma with the long-term corticosteroid therapy used with transplantation. Regular oral hygiene and follow-up dental care, with administration of prophylactic antibiotics before dental treatments, are recommended because of the immunosuppression. The nurse reminds the patient that although a successful transplantation will not return him or her to normal, it does increase the chances for survival and a more normal life than before transplantation if rejection and infection can be prevented. Many patients have lived successful and productive lives after receiving a liver transplant. In fact, pregnancy can be considered 1 year after transplantation. Successful outcomes have been reported, but these pregnancies are considered high risk for mother and infant (Sherlock & Dooley, 2002).
Liver Abscesses Two categories of liver abscess have been identified: amebic and pyogenic. Amebic liver abscesses are most commonly caused by Entamoeba histolytica. Most amebic liver abscesses occur in the developing countries of the tropics and subtropics because of poor sanitation and hygiene. Pyogenic liver abscesses are much less common but are more common in developed countries than the amebic type.
Pathophysiology Whenever an infection develops anywhere along the biliary or GI tract, infecting organisms may reach the liver through the biliary system, portal venous system, or hepatic arterial or lymphatic
Chapter 39
Assessment and Management of Patients With Hepatic Disorders
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NURSING RESEARCH PROFILE 39-1
The Experience of Liver Failure and Liver Transplantation Robertson, G. (1999). Individuals’ perception of their quality of life following a liver transplant: An exploratory study. Journal of Advanced Nursing, 30(2), 497–505.
Purpose Although advances in liver transplantation have increased the survival of persons who undergo the procedure, little is known about their quality of life. This study explored individuals’ perceptions of the effect a liver transplant had on their quality of life and focused on the progression from dependence to independence physically, socially, and psychologically. Study Sample and Design A phenomenologic approach was used; patients were interviewed in the outpatient clinic. Interviews were audiotaped and transcribed. Cluster analysis was used to identify groups of shared issues. The sample included five patients who had undergone liver transplantation for chronic liver disease at least 1 year before the study. Participants were asked about their quality of life before and after transplantation, the meaning of a good quality of life, and the transition from being dependent before transplantation to independent. Findings Physical problems present before transplantation prevented the subjects from fulfilling personal goals and participating in their usual ac-
system. Most bacteria are destroyed promptly, but occasionally some gain a foothold. The bacterial toxins destroy the neighboring liver cells, and the resulting necrotic tissue serves as a protective wall for the organisms. Meanwhile, leukocytes migrate into the infected area. The result is an abscess cavity full of a liquid containing living and dead leukocytes, liquefied liver cells, and bacteria. Pyogenic abscesses of this type may be either single or multiple and small. Examples of causes of pyogenic liver abscess include cholangitis and abdominal trauma.
tivities. Their physical problems kept them from achieving a good quality of life. Following transplant, the subjects identified their interest in social integration and their desire to be treated normally. The return to independence was identified as the key factor in their quality of life. However, their family and friends restricted their return to independence by overprotecting them. The study participants identified the importance of support from liver transplant unit staff and other patients in their transition during the first 3 months following transplantation. Nursing Implications It is important to recognize the issues shared by liver transplant patients and to devise strategies to assist them in achieving independence after surgery. Patient and family education regarding factors such as overprotectiveness versus using good judgment in social situations can be explored before the transplant. Educating the patient’s family and friends about the need for independence is important in helping to improve the patient’s quality of life after liver transplantation.
ried out to evacuate the abscess material and promote healing. A catheter may be left in place for continuous drainage; the patient must be instructed about its management.
Medical Management Treatment includes IV antibiotic therapy; the specific antibiotic used in treatment depends on the organism identified. Continuous supportive care is indicated because of the serious condition of the patient. Open surgical drainage may be required if antibiotic therapy and percutaneous drainage are ineffective.
Clinical Manifestations The clinical picture is one of sepsis with few or no localizing signs. Fever with chills and diaphoresis, malaise, anorexia, nausea, vomiting, and weight loss may occur. The patient may complain of dull abdominal pain and tenderness in the right upper quadrant of the abdomen. Hepatomegaly, jaundice, anemia, and pleural effusion may develop. Sepsis and shock may be severe and life-threatening. In the past, the mortality rate was 100% because of the vague clinical symptoms, inadequate diagnostic tools, and inadequate surgical drainage of the abscess. With the aid of ultrasound, CT and MRI scans, and liver scans, early diagnosis and surgical drainage of the abscess have greatly reduced the mortality rate.
Assessment and Diagnostic Findings Blood cultures are obtained but may not identify the organism. Aspiration of the liver abscess, guided by ultrasound, CT, or MRI, may be performed to assist in diagnosis and to obtain cultures of the organism. Percutaneous drainage of pyogenic abscesses is car-
Nursing Management Although the manifestations of liver abscess vary with the type of abscess, most patients appear acutely ill. Others appear to be chronically ill and debilitated. The nursing management depends on the patient’s physical status and the medical management that is indicated. For patients who undergo evacuation and drainage of the abscess, monitoring of the drainage and skin care are imperative. Strategies must be implemented to contain the drainage and to protect the patient from other sources of infection. Vital signs are monitored to detect changes in the patient’s physical status. Deterioration in vital signs or the onset of new symptoms such as increasing pain, which may indicate rupture or extension of the abscess, is reported promptly. The nurse administers IV antibiotic therapy as prescribed. The white blood cell count and other laboratory test results are monitored closely for changes consistent with worsening infection. The nurse prepares the patient for discharge by providing instruction about symptom management, signs and symptoms that should be reported to the physician, management of drainage, and the importance of taking antibiotics as prescribed.
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Critical Thinking Exercises
1.
A 54-year-old man is admitted to the hospital with endstage liver disease due to postnecrotic cirrhosis from hepatitis C, which developed following a blood transfusion 9 years ago. He is on the waiting list for a liver transplant due to incapacitating ascites and until now has been managed at home with diuretics, low sodium intake, daily weights, and fluid restriction. He also requires a weekly ultrasound-guided paracentesis. He has become unresponsive to oral diuretics, and his ascites is quickly reaccumulating after the paracentesis. His serum blood urea nitrogen (BUN) and creatinine levels are also rising. He is admitted to the hospital to receive intravenous diuretics and for closer monitoring as his renal function worsens. His worsening condition has placed him high on the waiting list for a liver transplant. As his nurse, what nursing interventions would you anticipate? What are the educational needs of the patient and his family?
2.
A 59-year-old white woman received an orthotopic liver transplant 6 months ago. She did well postoperatively and was discharged on immunosuppressive therapy. She now presents with a low-grade fever (99.8° F), 5-lb weight gain, tenderness over her transplanted liver, and mild jaundice. She also reports that her urine has become dark and has decreased in amount over the past 2 weeks. Her liver function test results are abnormal. Additional laboratory test results reveal that the serum level of tacrolimus (one of her immunosuppressant medications) is subtherapeutic. Describe the relationship of each of her current symptoms to liver dysfunction. What treatment would you anticipate, and what are the nursing measures for her at this time? What explanation would you give to her for her symptoms?
3.
A 20-year-old college student has been diagnosed with hepatitis B. What teaching is warranted for this patient to prevent transmission to others and to reduce the risk of complications? What symptomatic treatment would you anticipate, and what are the nursing implications associated with treatment? How would patient teaching, treatment, and nursing implications differ if the patient’s diagnosis were hepatitis A? What instructions about hepatitis B or hepatitis A would you give to the patient’s family or roommates?
4.
A 66-year-old man is admitted to the hospital with a tentative diagnosis of bleeding esophageal varices. Describe the monitoring you would initiate. Describe the possible management strategies to prevent bleeding and to treat active bleeding of the esophageal varices. Identify the nursing implications for each of these strategies. How would medical management and nursing care be modified if the patient had chronic obstructive pulmonary disease in addition to esophageal varices?
REFERENCES AND SELECTED READINGS Books American Cancer Society. (2002). Cancer facts and figures. Atlanta: American Cancer Society. Bacon, B. R., & Di Bisceglie, A. M. (Eds). (2000). Liver disease. New York: Churchill Livingstone. Blumgart, L. H., & Fong, Y. (Eds). (2000). Surgery of the liver and biliary tract (3d ed.). London: WB Saunders.
Clavien, P. A. (Ed). (1999). Malignant liver tumors. Malden, MA: Blackwell Science. Dudek, S. G. (2001). Nutrition essentials for nursing practice (4th ed.). Philadelphia: Lippincott Williams & Wilkins. Evans, S. R. T., & Ascher, S. M. (Eds.) (1998). Hepatobiliary and pancreatic surgery. New York: Wiley-Liss. Ginns, L. C., Cosimi, A. B., & Morris, P. J. (Eds). (1999). Transplantation. Malden, MA: Blackwell Science. Greene, F. L., Page, D. L., Fleming, I. D. et al. (Eds.) (2002). AJCC cancer staging manual (6th ed.). New York: Springer-Verlag. Habib, N. A. (Ed). (2000). Hepatocellular carcinoma: Methods and protocols. Totowa, NJ: Humana Press. Maddrey, W. C., Schiff, E. R., & Sorrell, M. F. (Eds.) (2001). Transplantation of the liver (3d ed.). Philadelphia: Lippincott Williams & Wilkins. National Digestive Diseases Information Clearinghouse (NIDDK) (2000). Cirrhosis of the liver. NIH Publication No. 00-1134, Bethesda, MD. National Institutes of Health. National Institute on Alcohol Abuse and Alcoholism. (1999). Alcohol research and health: The journal of the national institution on alcohol and alcoholism. Alexandria, VA: U.S. Department of Health and Human Services. O’Grady, J. G., Lake, J. R., & Howdle, P. D. (Eds). (2000). Comprehensive clinical hepatology. London: Mosby. Porth, C. M. (2002). Pathophysiology: Concepts of altered health states (6th ed.). Philadelphia: Lippincott Williams & Wilkins. Schiff, E. R., Sorrell, M. F., & Maddrey, W. C. (1999). Schiff’s diseases of the liver (8th ed.). Philadelphia: Lippincott-Raven. Sherlock, S., & Dooley, J. (2002). Diseases of the liver and biliary system. Osney Mead, Oxford: Blackwell Science. Wolfe, M. M. (2000). Therapy of digestive disorders. Philadelphia: WB Saunders. Zimmerman, H. J. (1999). Hepatotoxicity: The adverse effects of drugs and other chemicals on the liver (2d ed.). Philadelphia: Lippincott Williams & Wilkins.
Journals Asterisks indicate nursing research articles. General Angulo, P. (2002). Nonalcoholic fatty liver disease. New England Journal of Medicine, 346(16), 1221–1231. Blow, F. C., Walton, M. A., Barry, K. L., et al. (2000). The relationship between alcohol problems and health functioning of older adults in primary care settings. Journal of American Geriatrics Society, 48(7), 856–908. Bravo, A. A., Sheth, S. G., & Chopra, S. (2001). Liver biopsy. New England Journal of Medicine, 344(7), 495–500. Chikritzhs, T. N., Jonas, H. A., Stockwell, T. R., et al. (2001). Mortality and life years lost due to alcohol: A comparison of acute and chronic causes. Medical Journal of Australia, 174(6), 281–284. Fingerhood, M. (2000). Substance abuse in older people. Journal of the American Geriatrics Society, 48(8), 86–99. Garcia, N., Jr. & Sanyal, A. J. (2001). Portal hypertension. Clinics in Liver Disease, 5(2), 509–540. Hussain, H., Lapin, S., & Cappell, M. S. (2000). Clinical scoring systems for determining the prognosis of gastrointestinal bleeding. Gastroenterology Clinics, 29(2), 46–59. Kaptanoglu, L., & Blei, A. T. (2000). Current status of liver support systems. Clinics in Liver Disease, 4(3), 711–729. Jonsen, P. L. (2002). Liver disease in the elderly. Best Practice and Research in Clinical Gastroenterology, 16(1), 149–158. Lake, J. R. (2000). The role of transjugular portosystemic shunting in patients with ascites. New England Journal of Medicine, 342(23), 1745–1747. Maddrey, W. C. (2000). Alcohol-induced liver disease. Clinics in Liver Disease, 4(1), 115–131. Pastorelli, R., Bardozzi, G., Saieva, C., et al. (2001). Genetic determinants of alcohol addiction and metabolism: A survey in Italy. Alcoholism: Clinical and Experimental Research, 25(2), 221–227.
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Assessment and Management of Patients With Hepatic Disorders
Pratt, D. S., & Kaplan, M. M. (2000). Primary care: Evaluation of abnormal liver-enzyme results in asymptomatic patients. New England Journal of Medicine, 342(17), 1266–1271. Reynolds, T. B. (2000). Ascites. Clinics in Liver Disease, 4(1), 151–168. Schiff, E. R. (2000). Update in hepatology. Annals of Internal Medicine, 132(6), 460–466. Yu, A. S., & Hu, K. Q. (2001). Management of ascites. Clinics in Liver Disease, 5(2), 541–568. Zimmerman, H. J. (2000). Drug-induced liver disease. Clinics in Liver Disease, 4(1), 73–96. Cirrhosis and Esophageal Varices (2002). Medical consequences of alcohol abuse. Alcohol Research and Health: The Journal of the National Institute on Alcohol Abuse & Alcoholism, 24(1), 27–31. Chalasani, N., & Imperiale, T. F. (2001). Screening for varices in patients with cirrhosis: Where do we stand? American Journal of Gastroenterology, 96(3), 623–624. de Franchis, R. (2000). Updating consensus: Portal hypertension: Report of the Bavena III Consensus Workshop on definitions, methodology, and therapeutic strategies in portal hypertension. Journal of Hepatology, 33(5), 846–852. Inadomi, J. M., Kapur, S., Kinkhabwala, M., & Cello, J. P. (2001). The laparoscopic evaluation of ascites. Gastrointestinal Endoscopy Clinics of North America, 11(1), 79–91. Krige, J. J., & Beckingham, I. J. (2001). Portal hypertension. British Medical Journal, 322(7283), 348–351, 416–418. Menon, K. V., & Kamath, P. S. (2000). Managing the complications of cirrhosis. Mayo Clinic Proceedings, 75(5), 501–509. Orozco, H., & Mercado, M. A. (2000). The evolution of portal hypertension: Lessons from 1,000 operations and 50 years’ experience. Archives of Surgery, 135(12), 1389–1393. Pomier-Layrargues, G., Villeneuve, J. P., Deschenes, M., et al. (2001). Transjugular intrahepatic portosystemic shunts (TIPS) versus endoscopic variceal ligation in the prevention of variceal rebleeding in patients with cirrhosis: A randomized trial. Gut, 48(3), 390–396. Sarin, S. K., Lamba, G. S., Kumar, M., et al. (1999). Comparison of endoscopic ligation and propanolol for the primary prevention of variceal bleeding. New England Journal of Medicine, 340(13), 988–993. Seymour, C. A., & Whelan, K. (1999). Dietary management of hepatic encephalopathy: Too many myths persist. British Medical Journal, 318(7195), 1364–1365. Sharara, A. I., & Rockey, D. C. (2001). Medical progress: Gastroesophageal variceal hemorrhage. New England Journal of Medicine, 345(9), 669–681. Hepatitis Al-Saden, P. C., McPartlin, F., Daly-Gawenda, D., et al. (1999). Hepatitis C: An emerging dilemma. AAOHN Journal, 47(5), 217–222. Befeler, A. S., & Di Bisceglie, A. M. (2000). Hepatitis B. Infectious Disease Clinics of North America, 14(3), 617–632. Birkel, A., Caldwell, L., Stafford-Fox, V., et al. (2000). Combination interferon alfa-2b/ribavirin therapy for the treatment of hepatitis C: Nursing implications. Gastroenterology Nursing, 23(2), 55–62. Bockhold, K. M. (2000). Who’s afraid of hepatitis C? American Journal of Nursing, 100(5), 26–32. Centers for Disease Control and Prevention (CDC). (2002). Sexually transmitted diseases treatment guidelines 2002. MMWR: Morbidity and Mortality Weekly Report, 51(RR-6), 1–84. Centers for Disease Control and Prevention (CDC). (2001). FDA approval for a combined hepatitis A and B vaccine. MWWR: Morbidity and Mortality Weekly Report, 50(37), 806–807. Centers for Disease Control and Prevention (CDC). (1999). Prevention of hepatitis A through active or passive immunizations: Recommendations of the Advisory Committee on Immunization Practice (ACIP). MMWR: Morbidity and Mortality Weekly Report, 48(RR-12), 1–37. Chang, M. H. (2000). Hepatitis B vaccination and control of hepatitis B-related liver disease. Journal of Pediatric Gastroenterology and Nutrition, 31(2), 112–117.
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Chang, M. H., Shau, W. Y., & Chen, C. J. (2000). Hepatitis B vaccination and hepatocellular carcinoma rates in boys and girls. Journal of the American Medical Association, 284(23), 3040–3042. Cheney, C. P., Chopra, S., & Graham, C. (2000). Hepatitis C. Infectious Disease Clinics of North America, 14(3), 633–659. Di Bisceglie, A. M., Thompson, J., et al. (2001). Combination of interferon and ribavirin in chronic hepatitis C: Re-treatment of non-responders to interferon. Hepatology, 33(3), 704–707. Dougherty, A. S., & Dreher, H. M. (2001). Hepatitis C: Current treatment strategies for an emerging epidemic. MedSurg Nursing, 10(1), 9–15. Fried, M. W. (2001). Advances in therapy for chronic hepatitis C. Clinics in Liver Disease, 5(4), 1009–1023. Kenny-Walsh, E. (2001). The natural history of hepatitis C virus infection. Clinics in Liver Disease, 5(4), 969–977. Koff, R. S. (2001). Hepatitis vaccines. Infectious Disease Clinics of North America, 15(1), 83–93. Lauer, G. M., & Walker, B. D. (2001). Hepatitis C virus infection. New England Journal of Medicine, 345(1), 41–52. Lin, O. S., & Keeffe, E. B. (2001). Current treatment strategies for chronic hepatitis B and C. Annual Review of Medicine, 52, 29–49. National Institutes of Health (1997). Management of hepatitis C. NIH Consensus Statement Online, 15(3), 1–41. Ostapowicz, G., Fontana, R. J., Schiodt, F. V., et al. (2002). Results of a prospective study of acute liver failure at 17 tertiary care centers in the United States. Annals of Internal Medicine, 137(12), 947–954. Regev, A., & Schiff, E. R. (2000). Viral hepatitis A, B, and C. Clinics in Liver Disease, 4(1), 47–71. Riordan, S. M., & Williams, R. (2000). Fulminant liver failure. Clinics in Liver Disease, 4(1), 25–45. Ryder, S. D., & Beckingham, I. J. (2001). Acute hepatitis: Clinical review: ABC of diseases of liver, pancreas, and biliary system. British Medical Journal, 322(7279), 151–153. Sheffield, J. V., Larson, E. B., Gillock, M. R., et al. (2001). Update in general internal medicine. Annals of Internal Medicine, 135(4), 269–278. Shovein, J. T., Damazo, R. J., & Hyams, I. (2000). Hepatitis A: How benign is it? American Journal of Nursing, 100(3), 43–47. Thomas, D. L., Astemborski, J., Rai, R. M., et al. (2000). The natural history of hepatitis C virus infection: Host, viral and environmental factors. Journal of the American Medical Association, 284(4), 450–456. Wong, J. B., McQuillan, G. M., McHutchinson, J. G., & Poynard, T. (2000). Estimating future hepatitis C morbidity, mortality and costs in the United States. American Journal of Public Health, 90(10), 1562–1569. Wu, J. S., Hwang, L. Y., Goodman, K. J., et al. (1999). Hepatitis B vaccination in high-risk infants: 10-year follow-up. Journal of Infectious Diseases, 179(6), 1319–1325. Yashida, H., Arakawa, Y., Sata, M., et al. (2002). Interferon therapy prolonged life expectancy among chronic hepatitis C patients. Gastroenterology, 123(2), 483–491. Liver Cancer Aguayo, A., & Patt, Y. Z. (2001). Liver cancer. Clinics in Liver Disease, 5(2), 479–507. Gonzalez, K. B. & Woodall, M. (2001). Hepatocellular carcinoma: Surgical treatment options. Nursing Clinics of North America, 36(3), 593–602. Nagasue, N., Ond, T., Yamanoi, A., et al. (2001). Prognostic factors and survival after hepatic resection for hepatocellular carcinoma without cirrhosis. British Journal of Surgery, 88(4), 515–522. Tsao, J. I., DeSanctis, J., Rossi, R. L., & Oberfield, R. A. (2000). Hepatic malignancies. Surgical Clinics of North America, 80(2), 18–32. Liver Transplantation Dabbs, A. D., Dauber, J. H., & Hoffman, L. A. (2000). Rejection after organ transplantation: A historical review. American Journal of Critical Care, 9(6), 419–429. *Forsberg, A., Backman, L., & Moller, A. (2000). Experiencing liver transplantation: A phenomenological approach. Journal of Advanced Nursing, 32(2), 327–334.
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Gomez-Manero, N., Herrero, J. I., Quiroga, J., et al. (2001). Prognostic model for early acute rejection after liver transplant. Liver Transplantation, 7(3), 246–254. Gopal, D. V., Rabkin, J. M., Berk, B. S., et al. (2001). Treatment of progressive hepatitis C recurrence after liver transplantation with combination interferon plus ribavirin. Liver Transplantation, 7(3), 181–190. Hebert, M. F., Ascher, M. L., Lake, J. R., et al. (1999). Four-year follow-up of mycophenolate mofetil for grant rescue in liver allograft recipients. Transplantation, 67(5), 707–712. Niklason, L. E., & Langer, R. (2001). Prospects for organ and tissue replacement. Journal of the American Medical Association, 285(5), 573–576. *Robertson, G. (1999). Individuals’ perception of their quality of life following a liver transplant: An exploratory study. Journal of Advanced Nursing, 30(2), 497–505. Surman, O. S. (2002). The ethics of partial-liver donation. New England Journal of Medicine, 346(14), 1038. Trotter, J. F., Wachs, M., Everson, G. T., & Kam, I. (2002). Adult-toadult transplantation of the right hepatic lobe from a living donor. New England Journal of Medicine, 346(14), 1074–1082. Watson, C. J., Friend, P. J., Jamieson, N. V., et al. (1999). Sirolimus: A potent new immunosuppressant for liver transplantation. Transplantation, 67(4), 505–509.
RESOURCES AND WEBSITES Alcoholics Anonymous World Services, 475 Riverside Drive, 11th Floor, New York, NY 10115; (212) 870-3400; http://aa.org. Al-Anon Family Group Headquarters, 1600 Corporate Landing Parkway, Virginia Beach, VA 23454-5617; for meetings, (800) 3442666 (8 a.m. to 6 p.m., Monday through Friday); for information, (800) 356-9996 (7 days a week, 24 hours); http://www.al-anon. alateen.org. American Liver Foundation, 75 Maiden Lane, Suite 603, New York, NY 10038; (800) 465-4837; http://www.liverfoundation.org. Hepatitis Foundation International, 30 Sunrise Terrace, Cedar Grove, NJ 07009; (800) 891-0707; http://www.hepfi.org. National Council on Alcoholism and Drug Dependence, 12 W. 21st St., New York, NY 10010; (800) NCA-CALL; http://www.ncadd.org. National Digestive Diseases Information Clearing House, 2 Information Way, Bethesda, MD 20892-3570; (301) 654-3810; http://www.niddk. nih.gov. National Institute on Alcohol Abuse and Alcoholism, Scientific Communications Branch, 6000 Executive Boulevard, Suite 409, Bethesda, MD 20892-7003; (301) 443-3860; http://www.niaaa.nih.gov.
Chapter
40 ●
Assessment and Management of Patients With Biliary Disorders
LEARNING OBJECTIVES
●
On completion of this chapter, the learner will be able to: 1. Compare approaches to management of cholelithiasis. 2. Use the nursing process as a framework for care of patients with 3. 4. 5.
cholelithiasis and those undergoing laparoscopic or open cholecystectomy. Differentiate between acute and chronic pancreatitis. Use the nursing process as a framework for care of patients with acute pancreatitis. Describe the nutritional and metabolic effects of surgical treatment of tumors of the pancreas.
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isorders of the biliary tract and pancreas are common and include gallbladder stones and pancreatic dysfunction. An understanding of the structure and function of the biliary tract and pancreas is essential, along with an understanding of the close link of biliary tract disorders with liver disease. Patients with acute or chronic biliary tract or pancreatic disease require care from nurses knowledgeable about the diagnostic procedures and interventions that are used in the management of gallbladder and pancreatic disorders.
Anatomic and Physiologic Overview ANATOMY OF THE GALLBLADDER The gallbladder, a pear-shaped, hollow, saclike organ, 7.5 to 10 cm (3 to 4 in) long, lies in a shallow depression on the inferior surface of the liver, to which it is attached by loose connective tissue. The capacity of the gallbladder is 30 to 50 mL of bile. Its wall is composed largely of smooth muscle. The gallbladder is connected to the common bile duct by the cystic duct (Fig. 40-1).
FUNCTION OF THE GALLBLADDER The gallbladder functions as a storage depot for bile. Between meals, when the sphincter of Oddi is closed, bile produced by the hepatocytes enters the gallbladder. During storage, a large portion of the water in bile is absorbed through the walls of the gallbladder, so that gallbladder bile is five to ten times more concentrated than that originally secreted by the liver. When food enters the duodenum, the gallbladder contracts and the sphincter of Oddi (located at the junction where the common bile duct enters the duodenum) relaxes. Relaxation of the sphincter of Oddi allows the bile to enter the intestine. This response is mediated by secretion of the hormone cholecystokinin–pancreozymin (CCK-PZ) from the intestinal wall. Bile is composed of water and electrolytes (sodium, potassium, calcium, chloride, and bicarbonate) and significant amounts of lecithin, fatty acids, cholesterol, bilirubin, and bile salts. The bile salts, together with cholesterol, assist in emulsification of fats in the distal ileum. They then are reabsorbed into the portal blood for return to the liver and again excreted into the bile. This pathway from hepa-
tocytes to bile to intestine and back to the hepatocytes is called the enterohepatic circulation. Because of the enterohepatic circulation, only a small fraction of the bile salts that enter the intestine are excreted in the feces. This decreases the need for active synthesis of bile salts by the liver cells. If the flow of bile is impeded (ie, with gallstones in the bile ducts), bilirubin, a pigment derived from the breakdown of red blood cells, does not enter the intestine. As a result, bilirubin levels in the blood increase. This results, in turn, in increased renal excretion of urobilinogen, which results from conversion of bilirubin in the small intestine, and decreased excretion in the stool. These changes produce many of the signs and symptoms seen in gallbladder disorders.
THE PANCREAS The pancreas, located in the upper abdomen, has endocrine as well as exocrine functions (see Fig. 40-1). The secretion of pancreatic enzymes into the gastrointestinal tract through the pancreatic duct represents its exocrine function. The secretion of insulin, glucagon, and somatostatin directly into the bloodstream represents its endocrine function.
Exocrine Pancreas The secretions of the exocrine portion of the pancreas are collected in the pancreatic duct, which joins the common bile duct and enters the duodenum at the ampulla of Vater. Surrounding the ampulla is the sphincter of Oddi, which partially controls the rate at which secretions from the pancreas and the gallbladder enter the duodenum. The secretions of the exocrine pancreas are digestive enzymes high in protein content and an electrolyte-rich fluid. The secretions are very alkaline because of their high concentration of sodium bicarbonate and are capable of neutralizing the highly acid gastric juice that enters the duodenum. The enzyme secretions include amylase, which aids in the digestion of carbohydrates; trypsin, which aids in the digestion of proteins; and lipase, which aids in the digestion of fats. Other enzymes that promote the breakdown of more complex foodstuffs are also secreted.
Glossary amylase: pancreatic enzyme; aids in the digestion of carbohydrates cholecystitis: inflammation of the gallbladder cholecystokinin-pancreozymin (CCKPZ): hormone; major stimulus for digestive enzyme secretion; stimulates contraction of the gallbladder cholecystectomy: removal of the gallbladder cholecystojejunostomy: anastomosis of the jejunum to the gallbladder to divert bile flow cholecystostomy: opening and drainage of the gallbladder choledocholithiasis: stones in the common duct choledochostomy: opening into the common duct cholelithiasis: calculi in the gallbladder
dissolution therapy: use of medications to break up/dissolve gallstones endocrine: secreting internally; hormonal secretion of a ductless gland endoscopic retrograde cholangiopancreatography (ERCP): an endoscopic procedure using fiberoptic technology to visualize the biliary system exocrine: secreting externally; hormonal secretion from excretory ducts laparoscopic cholecystectomy: removal of gallbladder through endoscopic procedure lipase: pancreatic enzyme; aids in the digestion of fats lithotripsy: disintegration of gallstones by shock waves pancreaticojejunostomy: joining of the pancreatic duct to the jejunum by side-to-
side anastomosis; allows drainage of the pancreatic secretions into the jejunum pancreatitis: inflammation of the pancreas; may be acute or chronic secretin: hormone responsible for stimulating secretion of pancreatic juice; also used as an aid in diagnosing pancreatic exocrine disease and in obtaining desquamated pancreatic cells for cytologic examination steatorrhea: frothy, foul-smelling stools with a high fat content; results from impaired digestion of proteins and fats due to a lack of pancreatic juice in the intestine trypsin: pancreatic enzyme; aids in digestion of proteins Zollinger-Ellison tumor: hypersecretion of gastric acid that produces peptic ulcers as a result of a non-beta cell tumor of the pancreatic islets
Chapter 40
Assessment and Management of Patients With Biliary Disorders
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diaphragm
spleen liver common hepatic duct gallbladder pancreas
cystic duct
common bile duct
pancreatic duct duodenum
FIGURE 40-1
The liver, biliary system, and pancreas.
Hormones originating in the gastrointestinal tract stimulate the secretion of these exocrine pancreatic juices. Secretin is the major stimulus for increased bicarbonate secretion from the pancreas, and the major stimulus for digestive enzyme secretion is the hormone CCK-PZ. The vagus nerve also influences exocrine pancreatic secretion.
Endocrine Pancreas The islets of Langerhans, the endocrine part of the pancreas, are collections of cells embedded in the pancreatic tissue. They are composed of alpha, beta, and delta cells. The hormone produced by the beta cells is called insulin; the alpha cells secrete glucagon and the delta cells secrete somatostatin. INSULIN A major action of insulin is to lower blood glucose by permitting entry of the glucose into the cells of the liver, muscle, and other tissues, where it is either stored as glycogen or used for energy. Insulin also promotes the storage of fat in adipose tissue and the synthesis of proteins in various body tissues. In the absence of insulin, glucose cannot enter the cells and is excreted in the urine. This condition, called diabetes mellitus, can be diagnosed by high levels of glucose in the blood. In diabetes mellitus, stored fats and protein are used for energy instead of glucose, with consequent loss of body mass. (Diabetes mellitus is discussed in detail in Chap. 41.) The level of glucose in the blood normally regulates the rate of insulin secretion from the pancreas. GLUCAGON The effect of glucagon (opposite to that of insulin) is chiefly to raise the blood glucose by converting glycogen to glucose in the
liver. Glucagon is secreted by the pancreas in response to a decrease in the level of blood glucose. SOMATOSTATIN Somatostatin exerts a hypoglycemic effect by interfering with release of growth hormone from the pituitary and glucagon from the pancreas, both of which tend to raise blood glucose levels.
Endocrine Control of Carbohydrate Metabolism Glucose for body energy needs is derived by metabolism of ingested carbohydrates and also from proteins by the process of gluconeogenesis. Glucose can be stored temporarily in the liver, muscles, and other tissues in the form of glycogen. The endocrine system controls the level of blood glucose by regulating the rate at which glucose is synthesized, stored, and moved to and from the bloodstream. Through the action of hormones, blood glucose is normally maintained at about 100 mg/dL (5.5 mmol/L). Insulin is the primary hormone that lowers the blood glucose level. Hormones that raise the blood glucose level are glucagon, epinephrine, adrenocorticosteroids, growth hormone, and thyroid hormone. The endocrine and exocrine functions of the pancreas are interrelated. The major exocrine function is to facilitate digestion through secretion of enzymes into the proximal duodenum. Secretin and CCK-PZ are hormones from the gastrointestinal tract that aid in the digestion of food substances by controlling the secretions of the pancreas. Neural factors also influence pancreatic enzyme secretion. Considerable dysfunction of the pancreas must occur before enzyme secretion decreases and protein and fat digestion becomes impaired. Pancreatic enzyme secretion is normally 1,500 to 2,500 mL/day.
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Gerontologic Considerations There is little change in the size of the pancreas with age. There is, however, an increase in fibrous material and some fatty deposition in the normal pancreas in patients older than 70 years of age. Some localized arteriosclerotic changes occur with age. There is also a decreased rate of pancreatic secretion (decreased lipase, amylase, and trypsin) and bicarbonate output in older patients. Some impairment of normal fat absorption occurs with increasing age, possibly because of delayed gastric emptying and pancreatic insufficiency. Decreased calcium absorption may also occur. These changes require care in interpreting diagnostic tests in the normal elderly person and in providing dietary counseling.
Disorders of the Gallbladder Several disorders affect the biliary system and interfere with normal drainage of bile into the duodenum. These disorders include inflammation of the biliary system and carcinoma that obstructs the biliary tree. Gallbladder disease with gallstones is the most common disorder of the biliary system. Although not all occurrences of gallbladder inflammation (cholecystitis) are related to gallstones (cholelithiasis), more than 90% of patients with acute cholecystitis have gallstones. Most of the 15 million Americans with gallstones have no pain, however, and are unaware of the presence of stones. For a guide to the terminology associated with biliary disorders and procedures, see Chart 40-1.
CHOLECYSTITIS Acute inflammation (cholecystitis) of the gallbladder causes pain, tenderness, and rigidity of the upper right abdomen that may radiate to the midsternal area or right shoulder and is associated with nausea, vomiting, and the usual signs of an acute inflammation. An empyema of the gallbladder develops if the gallbladder becomes filled with purulent fluid. Calculous cholecystitis is the cause of more than 90% of cases of acute cholecystitis (Ahmed, Cheung & Keefe, 2000). In calculous cholecystitis, a gallbladder stone obstructs bile outflow.
Chart 40-1
Definition of Terms: Biliary
Cholecystitis: inflammation of the gallbladder Cholelithiasis: the presence of calculi in the gallbladder Cholecystectomy: removal of the gallbladder Cholecystostomy: opening and drainage of the gallbladder Choledochotomy: opening into the common duct Choledocholithiasis: stones in the common duct Choledocholithotomy: incision of common bile duct for removal of stones Choledochoduodenostomy: anastomosis of common duct to duodenum Choledochojejunostomy: anastomosis of common duct to jejunum Lithotripsy: disintegration of gallstones by shock waves Laparoscopic cholecystectomy: removal of gallbladder through endoscopic procedure Laser cholecystectomy: removal of gallbladder using laser rather than scalpel and traditional surgical instruments
Bile remaining in the gallbladder initiates a chemical reaction; autolysis and edema occur; and the blood vessels in the gallbladder are compressed, compromising its vascular supply. Gangrene of the gallbladder with perforation may result. Bacteria play a minor role in acute cholecystitis; however, secondary infection of bile with Escherichia coli, Klebsiella species, and other enteric organisms occurs in about 60% of patients (Schwartz, 1999). Acalculous cholecystitis describes acute gallbladder inflammation in the absence of obstruction by gallstones. Acalculous cholecystitis occurs after major surgical procedures, severe trauma, or burns. Other factors associated with this type of cholecystitis include torsion, cystic duct obstruction, primary bacterial infections of the gallbladder, and multiple blood transfusions. It is speculated that acalculous cholecystitis results from alterations in fluids and electrolytes and in regional blood flow in the visceral circulation. Bile stasis (lack of gallbladder contraction) and increased viscosity of the bile are also thought to play a role. The occurrence of acalculous cholecystitis with major surgical procedures or trauma makes its diagnosis difficult.
CHOLELITHIASIS Calculi, or gallstones, usually form in the gallbladder from the solid constituents of bile; they vary greatly in size, shape, and composition (Fig. 40-2). They are uncommon in children and young adults but become increasingly prevalent after 40 years of age. The incidence of cholelithiasis increases thereafter to such an extent that up to 50% of those over the age of 70 and over 50% of those over 80 will develop stones in the bile tract (Borzellino, deManzoni & Ricci, 1999). Chart 40-2 identifies common risk factors.
Pathophysiology There are two major types of gallstones: those composed predominantly of pigment and those composed primarily of cholesterol. Pigment stones probably form when unconjugated pigments in the bile precipitate to form stones; these stones account for about one third of cases in the United States (Donovan, 1999). The risk of developing such stones is increased in patients with cirrhosis, hemolysis, and infections of the biliary tract. Pigment stones cannot be dissolved and must be removed surgically. Cholesterol stones account for most of the remaining cases of gallbladder disease in the United States. Cholesterol, a normal constituent of bile, is insoluble in water. Its solubility depends on bile acids and lecithin (phospholipids) in bile. In gallstone-prone patients, there is decreased bile acid synthesis and increased cholesterol synthesis in the liver, resulting in bile supersaturated with cholesterol, which precipitates out of the bile to form stones. The cholesterol-saturated bile predisposes to the formation of gallstones and acts as an irritant, producing inflammatory changes in the gallbladder. Four times more women than men develop cholesterol stones and gallbladder disease; the women are usually older than 40, multiparous, and obese. The incidence of stone formation rises in users of oral contraceptives, estrogens, and clofibrate; these substances are known to increase biliary cholesterol saturation. The incidence of stone formation increases with age as a result of increased hepatic secretion of cholesterol and decreased bile acid synthesis. In addition, there is an increased risk because of malabsorption of bile salts in patients with gastrointestinal disease or
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Assessment and Management of Patients With Biliary Disorders
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FIGURE 40-2 Examples of cholesterol gallstones (left) made up of a coalescence of multiple small stones (left) and pigment gallstones (right) composed of calcium bilirubinate. Rubin, E., & Farber, J. L. (1999). Pathology (3rd ed.). Philadelphia: Lippincott Williams & Wilkins. T-tube fistula or in those who have had ileal resection or bypass. The incidence also increases in people with diabetes.
Clinical Manifestations Gallstones may be silent, producing no pain and only mild gastrointestinal symptoms. Such stones may be detected incidentally during surgery or evaluation for unrelated problems. The patient with gallbladder disease from gallstones may develop two types of symptoms: those due to disease of the gallbladder itself and those due to obstruction of the bile passages by a gallstone. The symptoms may be acute or chronic. Epigastric distress, such as fullness, abdominal distention, and vague pain in the right upper quadrant of the abdomen, may occur. This distress may follow a meal rich in fried or fatty foods.
Chart 40-2
Risk Factors for Cholelithiasis • Obesity • Women, especially those who have had multiple pregnancies • • • • • • •
or who are of Native American or U.S. Southwestern Hispanic ethnicity Frequent changes in weight Rapid weight loss (leads to rapid development of gallstones and high risk of symptomatic disease) Treatment with high-dose estrogen (ie, in prostate cancer) Low-dose estrogen therapy—a small increase in the risk of gallstones Ileal resection or disease Cystic fibrosis Diabetes mellitus
PAIN AND BILIARY COLIC If a gallstone obstructs the cystic duct, the gallbladder becomes distended, inflamed, and eventually infected (acute cholecystitis). The patient develops a fever and may have a palpable abdominal mass. The patient may have biliary colic with excruciating upper right abdominal pain that radiates to the back or right shoulder, is usually associated with nausea and vomiting, and is noticeable several hours after a heavy meal. The patient moves about restlessly, unable to find a comfortable position. In some patients the pain is constant rather than colicky. Such a bout of biliary colic is caused by contraction of the gallbladder, which cannot release bile because of obstruction by the stone. When distended, the fundus of the gallbladder comes in contact with the abdominal wall in the region of the right ninth and tenth costal cartilages. This produces marked tenderness in the right upper quadrant on deep inspiration and prevents full inspiratory excursion. The pain of acute cholecystitis may be so severe that analgesics are required. Morphine is thought to increase spasm of the sphincter of Oddi and may be avoided in many cases in favor of meperidine (Porth, 2002). This is controversial because morphine is the preferred analgesic agent for management of acute pain, and meperidine has metabolites toxic to the CNS. If the gallstone is dislodged and no longer obstructs the cystic duct, the gallbladder drains and the inflammatory process subsides after a relatively short time. If the gallstone continues to obstruct the duct, abscess, necrosis, and perforation with generalized peritonitis may result. JAUNDICE Jaundice occurs in a few patients with gallbladder disease and usually occurs with obstruction of the common bile duct. The bile, which is no longer carried to the duodenum, is absorbed
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by the blood and gives the skin and mucous membrane a yellow color. This is frequently accompanied by marked itching of the skin. CHANGES IN URINE AND STOOL COLOR The excretion of the bile pigments by the kidneys gives the urine a very dark color. The feces, no longer colored with bile pigments, are grayish, like putty, and usually described as clay-colored. VITAMIN DEFICIENCY Obstruction of bile flow also interferes with absorption of the fatsoluble vitamins A, D, E, and K. Therefore, the patient may exhibit deficiencies (eg, bleeding caused by vitamin K deficiency, which interferes with normal blood clotting) of these vitamins if biliary obstruction has been prolonged.
Assessment and Diagnostic Findings ABDOMINAL X-RAY An abdominal x-ray may be obtained if gallbladder disease is suggested to exclude other causes of symptoms. However, only 15% to 20% of gallstones are calcified sufficiently to be visible on such x-ray studies. ULTRASONOGRAPHY Ultrasonography has replaced oral cholecystography as the diagnostic procedure of choice because it is rapid and accurate and can be used in patients with liver dysfunction and jaundice. It does not expose patients to ionizing radiation. The procedure is most accurate if the patient fasts overnight so that the gallbladder is distended. The use of ultrasound is based on reflected sound waves. Ultrasonography can detect calculi in the gallbladder or a dilated common bile duct. It is reported to detect gallstones with 95% accuracy. RADIONUCLIDE IMAGING OR CHOLESCINTIGRAPHY Cholescintigraphy is used successfully in the diagnosis of acute cholecystitis. In this procedure, a radioactive agent is administered intravenously. It is taken up by the hepatocytes and excreted rapidly through the biliary tract. The biliary tract is then scanned, and images of the gallbladder and biliary tract are obtained. This test is more expensive than ultrasonography, takes longer to perform, exposes the patient to radiation, and cannot detect gallstones. Its use may be limited to cases in which ultrasonography is not conclusive. CHOLECYSTOGRAPHY Although it has been replaced by ultrasonography as the test of choice, cholecystography is still used if ultrasound equipment is not available or if the ultrasound results are inconclusive. Oral cholangiography may be performed to detect gallstones and to assess the ability of the gallbladder to fill, concentrate its contents, contract, and empty. An iodide-containing contrast agent excreted by the liver and concentrated in the gallbladder is administered to the patient. The normal gallbladder fills with this radiopaque substance. If gallstones are present, they appear as shadows on the x-ray film. Contrast agents include iopanoic acid (Telepaque), iodipamide meglumine (Cholografin), and sodium ipodate (Oragrafin). These agents are administered orally 10 to 12 hours before the x-ray study. To prevent contraction and emptying of the gallbladder, the patient is permitted nothing by mouth after the contrast agent is administered.
The patient is asked about allergies to iodine or seafood. If no allergy is identified, the patient receives the oral form of the contrast agent the evening before the x-rays are obtained. An x-ray of the right upper abdomen is obtained. If the gallbladder is found to fill and empty normally and to contain no stones, gallbladder disease is ruled out. If gallbladder disease is present, the gallbladder may not be visualized because of obstruction by gallstones. A repeat of the oral cholecystogram with a second dose of the contrast agent may be necessary if the gallbladder is not visualized on the first attempt. Cholecystography in the obviously jaundiced patient is not useful because the liver cannot excrete the radiopaque dye into the gallbladder in the presence of jaundice. Oral cholecystography is likely to continue to be used as part of the evaluation of the few patients who have been treated with gallstone dissolution therapy or lithotripsy. ENDOSCOPIC RETROGRADE CHOLANGIOPANCREATOGRAPHY Endoscopic retrograde cholangiopancreatography (ERCP) permits direct visualization of structures that could once be seen only during laparotomy. The examination of the hepatobiliary system is carried out via a side-viewing flexible fiberoptic endoscope inserted into the esophagus to the descending duodenum (Fig. 40-3). Multiple position changes are required during the procedure, beginning in the left semiprone position to pass the endoscope. Fluoroscopy and multiple x-rays are used during ERCP to evaluate the presence and location of ductal stones. Careful insertion of a catheter through the endoscope into the common bile duct is the most important step in sphincterotomy (division of the muscles of the biliary sphincter) for gallstone extraction via this technique. This is described later in the chapter. Nursing Implications. The procedure requires a cooperative patient to permit insertion of the endoscope without damage to the gastrointestinal tract structures, including the biliary tree. Before
Biliary tree Ampulla of Vater Pancreatic ductal system Fiberoptic endoscope
FIGURE 40-3
Endoscopic retrograde cholangiopancreatography (ERCP). A fiberoptic duodenoscope, with side-viewing apparatus, is inserted into the duodenum. The ampulla of Vater is catheterized and the biliary tree injected with contrast agent. The pancreatic ductal system is also assessed, if indicated. This procedure is of special value in visualizing neoplasms of the ampulla area and extracting a biopsy specimen.
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Assessment and Management of Patients With Biliary Disorders
the procedure, the patient is given an explanation of the procedure and his or her role in it. The patient takes nothing by mouth for several hours before the procedure. Moderate sedation is used with this procedure, so the sedated patient must be monitored closely. Most endoscopists use a combination of an opioid and a benzodiazepine. Medications such as glucagon or anticholinergics may also be necessary to eliminate duodenal peristalsis to make cannulation easier. The nurse observes closely for signs of respiratory and central nervous system depression, hypotension, oversedation, and vomiting (if glucagon is given). During ERCP, the nurse monitors intravenous fluids, administers medications, and positions the patient. After the procedure, the nurse monitors the patient’s condition, observing vital signs and monitoring for signs of perforation or infection. The nurse also monitors the patient for side effects of any medications received during the procedure and for return of the gag and cough reflexes after the use of local anesthetics. PERCUTANEOUS TRANSHEPATIC CHOLANGIOGRAPHY Percutaneous transhepatic cholangiography involves the injection of dye directly into the biliary tract. Because of the relatively large concentration of dye that is introduced into the biliary system, all components of the system, including the hepatic ducts within the liver, the entire length of the common bile duct, the cystic duct, and the gallbladder, are outlined clearly. This procedure can be carried out even in the presence of liver dysfunction and jaundice. It is useful for distinguishing jaundice caused by liver disease (hepatocellular jaundice) from that caused by biliary obstruction, for investigating the gastrointestinal symptoms of a patient whose gallbladder has been removed, for locating stones within the bile ducts, and for diagnosing cancer involving the biliary system. This sterile procedure is performed under moderate sedation on a patient who has been fasting; the patient receives local anesthesia and intravenous sedation. Coagulation parameters and platelet count should be normal to minimize the risk for bleeding. Broad-spectrum antibiotics are administered during the procedure due to the high prevalence of bacterial colonization from obstructed biliary systems. After infiltration with a
Table 40-1
local anesthetic agent, a flexible needle is inserted into the liver from the right side in the midclavicular line immediately beneath the right costal margin. Successful entry of a duct is noted when bile is aspirated or upon the injection of a contrast agent. Ultrasound guidance can be used for duct puncture. Bile is aspirated and samples are sent for bacteriology and cytology. A water-soluble contrast agent is injected to fill the biliary system. The fluoroscopy table is tilted and the patient repositioned to allow x-rays to be taken in multiple projections. Delayed x-ray views can identify abnormalities of more distant ducts and determine the length of a stricture or multiple strictures. Before the needle is removed, as much dye and bile as possible are aspirated to forestall subsequent leakage into the needle tract and eventually into the peritoneal cavity, thus minimizing the risk of bile peritonitis. Table 40-1 identifies various procedures and their diagnostic uses.
!
NURSING ALERT Although the complication rate after this procedure is low, the nurse must closely observe the patient for symptoms of bleeding, peritonitis, and septicemia. The nurse should immediately report pain and indicators of these complications. Antibiotic agents are often prescribed to minimize the risk of sepsis and septic shock.
Medical Management The major objectives of medical therapy are to reduce the incidence of acute episodes of gallbladder pain and cholecystitis by supportive and dietary management and, if possible, to remove the cause of cholecystitis by pharmacologic therapy, endoscopic procedures, or surgical intervention. Although nonsurgical approaches have the advantage of eliminating risks associated with surgery, they are associated with persistent symptoms or recurrent stone formation. Most of the nonsurgical approaches, including lithotripsy and dissolution of gallstones, provide only temporary solutions to the problems associated with gallstones. They are therefore rarely used in the United States. In some instances, other treatment approaches may be indicated; these are described below.
• Studies Used in the Diagnosis of Biliary Tract and Pancreatic Disease
STUDIES
DIAGNOSTIC USES
Cholecystogram, cholangiogram Celiac axis arteriography Laparoscopy
To visualize gallbladder and bile duct To visualize liver and pancreas To visualize anterior surface of liver, gallbladder, and mesentery through a trocar To show size of abdominal organs and presence of masses To detect neoplasms; diagnose cysts, abscess, and hematomas To visualize biliary structures and pancreas via endoscopy In absence of bone disease, to measure of biliary tract obstruction Markers for biliary stasis; also elevated in alcohol abuse Elevated in biliary obstruction; decreased in parenchymal liver disease
Ultrasonography Magnetic resonance imaging (MRI) Endoscopic retrograde cholangiopancreatography (ERCP) Serum alkaline phosphatase GGT, GGTP, LDH Cholesterol levels
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Removal of the gallbladder (cholecystectomy) through traditional surgical approaches was considered the standard approach to management for more than 100 years. However, dramatic changes have occurred in the surgical management of gallbladder disease. There is now widespread use of laparoscopic cholecystectomy (removal of the gallbladder through a small incision through the umbilicus). As a result, surgical risks have decreased, along with the length of hospital stay and the long recovery period associated with the standard surgical cholecystectomy. NUTRITIONAL AND SUPPORTIVE THERAPY Approximately 80% of the patients with acute gallbladder inflammation achieve remission with rest, intravenous fluids, nasogastric suction, analgesia, and antibiotic agents. Unless the patient’s condition deteriorates, surgical intervention is delayed until the acute symptoms subside and a complete evaluation can be carried out. The diet immediately after an episode is usually limited to low-fat liquids. The patient can stir powdered supplements high in protein and carbohydrate into skim milk. Cooked fruits, rice or tapioca, lean meats, mashed potatoes, non–gas-forming vegetables, bread, coffee, or tea may be added as tolerated. The patient should avoid eggs, cream, pork, fried foods, cheese and rich dressings, gas-forming vegetables, and alcohol. It is important to remind the patient that fatty foods may bring on an episode. Dietary management may be the major mode of therapy in patients who have had only dietary intolerance to fatty foods and vague gastrointestinal symptoms (Dudek, 2001). PHARMACOLOGIC THERAPY Ursodeoxycholic acid (UDCA) and chenodeoxycholic acid (chenodiol or CDCA) have been used to dissolve small, radiolucent gallstones composed primarily of cholesterol. UDCA has fewer side effects than chenodiol and can be administered in smaller doses to achieve the same effect. It acts by inhibiting the synthesis and secretion of cholesterol, thereby desaturating bile. Existing stones can be reduced in size, small ones dissolved, and new stones prevented from forming. Six to 12 months of therapy are required in many patients to dissolve stones, and monitoring of the patient is required during this time. The effective dose of medication depends on body weight. This method of treatment is generally indicated for patients who refuse surgery or for whom surgery is considered too risky. Patients with significant, frequent symptoms, cystic duct occlusion, or pigment stones are not candidates for this therapy. Symptomatic patients with acceptable operative risk are more appropriate for laparoscopic or open cholecystectomy. NONSURGICAL REMOVAL OF GALLSTONES Dissolving Gallstones. Several methods have been used to dissolve gallstones by infusion of a solvent (mono-octanoin or methyl tertiary butyl ether [MTBE]) into the gallbladder. The solvent can be infused through the following routes: a tube or catheter inserted percutaneously directly into the gallbladder; a tube or drain inserted through a T-tube tract to dissolve stones not removed at the time of surgery; an ERCP endoscope; or a transnasal biliary catheter. In the last procedure, the catheter is introduced through the mouth and inserted into the common bile duct. The upper end of the tube is then rerouted from the mouth to the nose and left in place. This enables the patient to eat and drink normally while passage of stones is monitored or chemical solvents are infused to dissolve the stones. This method of dissolution of stones is not widely used in patients with gallstone disease.
Stone Removal by Instrumentation. Several nonsurgical methods are used to remove stones that were not removed at the time of cholecystectomy or have become lodged in the common bile duct (Fig. 40-4A, B). A catheter and instrument with a basket attached are threaded through the T-tube tract or fistula formed at the time of T-tube insertion; the basket is used to retrieve and remove the stones lodged in the common bile duct. A second procedure involves the use of the ERCP endoscope (see Fig. 40-4C ). After the endoscope is inserted, a cutting instrument is passed through the endoscope into the ampulla of Vater of the common bile duct. It may be used to cut the submucosal fibers, or papilla, of the sphincter of Oddi, enlarging the opening, which may allow the lodged stones to pass spontaneously into the duodenum. Another instrument with a small basket or balloon at its tip may be inserted through the endoscope to retrieve the stones (see Fig. 40-4D–F ). Although complications after this procedure are rare, the patient must be observed closely for bleeding, perforation, and the development of pancreatitis or sepsis. The ERCP procedure is particularly useful in the diagnosis and treatment of patients who have symptoms after biliary tract surgery, for patients with intact gallbladders, and for patients in whom surgery is particularly hazardous. Extracorporeal Shock-Wave Lithotripsy. Extracorporeal shockwave therapy (lithotripsy or ESWL) has been used for nonsurgical fragmentation of gallstones. The word lithotripsy is derived from lithos, meaning stone, and tripsis, meaning rubbing or friction. This noninvasive procedure uses repeated shock waves directed at the gallstones in the gallbladder or common bile duct to fragment the stones. The energy is transmitted to the body through a fluid-filled bag, or it may be transmitted while the patient is immersed in a water bath. The converging shock waves are directed to the stones to be fragmented. After the stones are gradually broken up, the stone fragments pass from the gallbladder or common bile duct spontaneously, are removed by endoscopy, or are dissolved with oral bile acid or solvents. Because the procedure requires no incision and no hospitalization, patients are usually treated as outpatients, but several sessions are generally necessary. The advent of laparoscopic cholecystectomy has reduced the use of this method to treat gallbladder stones. It is used in some centers for a small percentage of suitable patients (those with common bile duct stones who may not be surgical candidates), sometimes in combination with dissolution therapy. Intracorporeal Lithotripsy. Stones in the gallbladder or common bile duct may be fragmented by means of laser pulse technology. A laser pulse is directed under fluoroscopic guidance with the use of devices that can distinguish between stones and tissue. The laser pulse produces rapid expansion and disintegration of plasma on the stone surface, resulting in a mechanical shock wave. Electrohydraulic lithotripsy uses a probe with two electrodes that deliver electric sparks in rapid pulses, creating expansion of the liquid environment surrounding the gallstones. This results in pressure waves that cause stones to fragment. This technique can be employed percutaneously with the use of a basket or balloon catheter system or by direct visualization through an endoscope. Repeated procedures may be necessary due to stone size, local anatomy, bleeding, or technical difficulty. A nasobiliary tube can be inserted to allow for biliary decompression and prevent stone impaction in the common bile duct. This approach allows time for improvement in the patient’s clinical condition until gallstones are cleared endoscopically, percutaneously, or surgically.
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T-tube tract T-tube Stone in common bile duct
Stone
Basket
Duodenum Endoscope
A
B T-tube tract to remove stone.
Pancreatic duct
C
Removal of stone with basket attached to catheter threaded through T-tube tract.
ERCP endoscope inserted into duodenum.
Sphincter of Oddi
E
D Papillotome inserted into common bile duct.
FIGURE 40-4
F
Enlarging opening of sphincter of Oddi.
Retrieval and removal of stone with basket inserted through endoscope.
Nonsurgical techniques for removing gallstones.
SURGICAL MANAGEMENT Surgical treatment of gallbladder disease and gallstones is carried out to relieve persistent symptoms, to remove the cause of biliary colic, and to treat acute cholecystitis. Surgery may be delayed until the patient’s symptoms have subsided or may be performed as an emergency procedure if the patient’s condition necessitates it. Preoperative Measures. A chest x-ray, electrocardiogram, and liver function tests may be performed in addition to x-ray studies of the gallbladder. Vitamin K may be administered if the prothrombin level is low. Blood component therapy may be administered before surgery. Nutritional requirements are considered; if the nutritional status is suboptimal, it may be necessary to provide intravenous glucose with protein hydrolysate supplements to aid wound healing and help prevent liver damage. Preparation for gallbladder surgery is similar to that for any upper abdominal laparotomy or laparoscopy. Instructions and explanations are given before surgery with regard to turning and deep breathing. Pneumonia and atelectasis are possible postoperative complications that can be avoided by deep-breathing exercises and frequent turning. The patient should be informed that drainage tubes and a nasogastric tube and suction may be required during the immediate postoperative period if an open cholecystectomy is performed. Laparoscopic Cholecystectomy. Laparoscopic cholecystectomy (Fig. 40-5) has dramatically changed the approach to the management of cholecystitis. It has become the new standard for therapy of symptomatic gallstones. Approximately 700,000 patients in the United States require surgery each year for removal of the gallbladder, and 80% to 90% of them are candidates for laparoscopic cholecystectomy (Bornman & Beckingham, 2001). If the
common bile duct is thought to be obstructed by a gallstone, an ERCP with sphincterotomy may be performed to explore the duct before laparoscopy. Before the procedure, the patient is informed that an open abdominal procedure may be necessary, and general anesthesia is administered. Laparoscopic cholecystectomy is performed through a small incision or puncture made through the abdominal wall in the umbilicus. The abdominal cavity is insufflated with carbon dioxide (pneumoperitoneum) to assist in inserting the laparoscope and to aid the surgeon in visualizing the abdominal structures. The fiberoptic scope is inserted through the small umbilical incision. Several additional punctures or small incisions are made in the abdominal wall to introduce other surgical instruments into the operative field. The surgeon visualizes the biliary system through the laparoscope; a camera attached to the scope permits a view of the intra-abdominal field to be transmitted to a television monitor. After the cystic duct is dissected, the common bile duct is imaged by ultrasound or cholangiography to evaluate the anatomy and identify stones. The cystic artery is dissected free and clipped. The gallbladder is separated away from the hepatic bed and dissected. The gallbladder is then removed from the abdominal cavity after bile and small stones are aspirated. Stone forceps also can be used to remove or crush larger stones. The advantage of the laparoscopic procedure is that the patient does not experience the paralytic ileus that occurs with open abdominal surgery and has less postoperative abdominal pain. The patient is often discharged from the hospital on the day of surgery or within a day or two and can resume full activity and employment within a week of the surgery. Conversion to a traditional abdominal surgical procedure may be necessary if problems are encountered during the laparoscopic procedure; this occurs in 2% to 8% of reported surgical cases.
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Gallbladder Liver
Pancreas
Operating port; dissector
Retractor
A
Dissector
Laparoscope
B
FIGURE 40-5
In (A) laparoscopic cholecystectomy, (B) the surgeon makes four small incisions (less than 1⁄2 inch each) in the abdomen and inserts a laparoscope with a miniature camera through the umbilical incision. The camera apparatus displays the gallbladder and adjacent tissues on a screen, allowing the surgeon to visualize the sections of the organ for removal.
Conversion is required more often, approximately 20% of the time, in those with acute cholecystitis (Lai et al., 1998). Careful screening of patients and identification of those at low risk for complications limits the frequency of conversion to an open abdominal procedure. With wider use of laparoscopic procedures, however, there may be an increase in the number of such conversions. The most serious complication after laparoscopic cholecystectomy is a bile duct injury. Because of the short hospital stay, it is important to provide written as well as verbal instructions about managing postoperative pain and reporting signs and symptoms of intra-abdominal complications, including loss of appetite, vomiting, pain, distention of the abdomen, and temperature elevation. Although recovery from laparoscopic cholecystectomy is rapid, patients are drowsy afterward. The nurse must ensure that the patient has assistance at home during the first 24 to 48 hours. If pain occurs in the right shoulder or scapular area (from migration of the CO2 used to insufflate the abdominal cavity during the procedure), the nurse may recommend use of a heating pad for 15 to 20 minutes hourly, walking, and sitting up when in bed. Cholecystectomy. In this procedure, the gallbladder is removed through an abdominal incision (usually right subcostal) after the cystic duct and artery are ligated. The procedure is performed for acute and chronic cholecystitis. In some patients a drain may be placed close to the gallbladder bed and brought out through a puncture wound if there is a bile leak. The drain type is chosen based on the physician’s preference. A small leak should close spontaneously in a few days with the drain preventing accumulation of bile. Usually only a small amount of serosanguinous fluid will drain in the initial 24 hours after surgery, and then the drain will be removed.
The drain is usually maintained if there is excess oozing or bile leakage. Use of a T-tube inserted into the common bile duct during the open procedure is now uncommon; it is used only in the setting of a complication (ie, retained common bile duct stone). Bile duct injury is a serious complication of this procedure but occurs less frequently than with the laparoscopic approach. Once one of the most common surgical procedures in the United States, this procedure has largely been replaced by laparoscopic cholecystectomy. Mini-cholecystectomy. Mini-cholecystectomy is a surgical procedure in which the gallbladder is removed through a small incision. If needed, the surgical incision is extended to remove large gallbladder stones. Drains may or may not be used. The cost savings resulting from the shorter hospital stay have been identified as a major reason for pursuing this type of procedure. Debate exists about this procedure because it limits exposure to all the involved biliary structures. Choledochostomy. Choledochostomy involves an incision into the common duct, usually for removal of stones. After the stones have been evacuated, a tube usually is inserted into the duct for drainage of bile until edema subsides. This tube is connected to gravity drainage tubing. The gallbladder also contains stones, and as a rule a cholecystectomy is performed at the same time. Surgical Cholecystostomy. Cholecystostomy is performed when the patient’s condition prevents more extensive surgery or when an acute inflammatory reaction is severe. The gallbladder is surgically opened, the stones and the bile or the purulent drainage are removed, and a drainage tube is secured with a purse-string suture. The drainage tube is connected to a drainage system to
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Assessment and Management of Patients With Biliary Disorders
prevent bile from leaking around the tube or escaping into the peritoneal cavity. After recovery from the acute episode, the patient may return for cholecystectomy. Despite its lower risk, surgical cholecystostomy has a high mortality rate (reported as high as 20% to 30%) because of the underlying disease process. Percutaneous Cholecystostomy. Percutaneous cholecystostomy has been used in the treatment and diagnosis of acute cholecystitis in patients who are poor risks for any surgical procedure or for general anesthesia. These may include patients with sepsis or severe cardiac, renal, pulmonary, or liver failure. Under local anesthesia, a fine needle is inserted through the abdominal wall and liver edge into the gallbladder under the guidance of ultrasound or computed tomography. Bile is aspirated to ensure adequate placement of the needle, and a catheter is inserted into the gallbladder to decompress the biliary tract. Almost immediate relief of pain and resolution of signs and symptoms of sepsis and cholecystitis have been reported with this procedure. Antibiotic agents are administered before, during, and after the procedure. Gerontologic Considerations Surgical intervention for disease of the biliary tract is the most common operative procedure performed in the elderly. Cholesterol saturation of bile increases with age due to increased hepatic secretion of cholesterol and decreased bile acid synthesis. Although the incidence of gallstones increases with age, the elderly patient may not exhibit the typical picture of fever, pain, chills, and jaundice. Symptoms of biliary tract disease in the elderly may be accompanied or preceded by those of septic shock, which include oliguria, hypotension, changes in mental status, tachycardia, and tachypnea. Although surgery in the elderly presents a risk because of preexisting associated diseases, the mortality rate from serious complications from biliary tract disease itself is also high. The risk of death and complications is increased in the elderly patient who undergoes emergency surgery for life-threatening disease of the biliary tract. Despite chronic illness in many elderly patients, elective cholecystectomy is usually well tolerated and can be carried out with low risk if expert assessment and care are provided before, during, and after the surgical procedure. Because of recent changes in the health care system, there has been a decrease in the number of elective surgical procedures performed, including cholecystectomies. As a result, patients requiring the procedure are seen in the later stages of disease. Simultaneously, patients undergoing surgery are increasingly older than 60 years of age and have complicated acute cholecystitis. The higher risk of complications and shorter hospital stays make it essential that older patients and their family members receive specific information about signs and symptoms of complications and measures to prevent them.
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complications. It also is important to instruct the patient to avoid the use of aspirin and other agents (over-the-counter medications and herbal remedies) that can alter coagulation and other biochemical processes. Assessment should focus on the patient’s respiratory status. If a traditional surgical approach is planned, the high abdominal incision required during surgery may interfere with full respiratory excursion. The nurse notes a history of smoking, previous respiratory problems, shallow respirations, a persistent or ineffective cough, and the presence of adventitious breath sounds. Nutritional status is evaluated through a dietary history and general examination performed at the time of preadmission testing. The nurse also reviews previously obtained laboratory results to obtain information about the patient’s nutritional status.
Diagnosis NURSING DIAGNOSES Based on all the assessment data, the major postoperative nursing diagnoses for the patient undergoing surgery for gallbladder disease may include the following:
• Acute pain and discomfort related to surgical incision • Impaired gas exchange related to the high abdominal surgi•
• •
cal incision (if traditional surgical cholecystectomy is performed) Impaired skin integrity related to altered biliary drainage after surgical intervention (if a T-tube is inserted because of retained stones in the common bile duct or another drainage device is employed) Imbalanced nutrition, less than body requirements, related to inadequate bile secretion Deficient knowledge about self-care activities related to incision care, dietary modifications (if needed), medications, reportable signs or symptoms (eg, fever, bleeding, vomiting)
COLLABORATIVE PROBLEMS/ POTENTIAL COMPLICATIONS Based on assessment data, potential complications may include:
• Bleeding • Gastrointestinal symptoms (may be related to biliary leak) Planning and Goals The goals for the patient include relief of pain, adequate ventilation, intact skin and improved biliary drainage, optimal nutritional intake, absence of complications, and understanding of self-care routines.
Postoperative Nursing Interventions
Assessment
After recovery from anesthesia, the nurse places the patient in the low Fowler’s position. Intravenous fluids may be given, and nasogastric suction (a nasogastric tube was probably inserted immediately before surgery for a nonlaparoscopic procedure) may be instituted to relieve abdominal distention. Water and other fluids are given in about 24 hours, and a soft diet is started when bowel sounds return.
The patient who is to undergo surgical treatment of gallbladder disease is often admitted to the hospital or same-day surgery unit on the morning of surgery. Preadmission testing is often completed a week or more before admission; at that time, the nurse instructs the patient about the need to avoid smoking to enhance pulmonary recovery postoperatively and to avoid respiratory
RELIEVING PAIN The location of the subcostal incision in nonlaparoscopic gallbladder surgery is likely to cause the patient to avoid turning and moving, to splint the affected site, and to take shallow breaths to prevent pain. Because full aeration of the lungs and gradually increased activity are necessary to prevent postoperative complica-
NURSING PROCESS: THE PATIENT UNDERGOING SURGERY FOR GALLBLADDER DISEASE
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tions, the nurse should administer analgesic agents as prescribed to relieve the pain and to promote well-being in addition to helping the patient turn, cough, breathe deeply, and ambulate as indicated. Use of a pillow or binder over the incision may reduce pain during these maneuvers. IMPROVING RESPIRATORY STATUS Patients undergoing biliary tract surgery are especially prone to pulmonary complications, as are all patients with upper abdominal incisions. Thus, the nurse reminds patients to take deep breaths and cough every hour to expand the lungs fully and prevent atelectasis. The early and consistent use of incentive spirometry also helps improve respiratory function. Early ambulation prevents pulmonary complications as well as other complications, such as thrombophlebitis. Pulmonary complications are more likely to occur in the elderly and in obese patients. PROMOTING SKIN CARE AND BILIARY DRAINAGE In patients who have undergone a cholecystostomy or choledochostomy, the drainage tubes must be connected immediately to a drainage receptacle. The nurse should fasten tubing to the dressings or to the patient’s gown, with enough leeway for the patient to move without dislodging or kinking it. Because a drainage system remains attached when the patient is ambulating, the drainage bag may be placed in a bathrobe pocket or fastened so that it is below the waist or common duct level. If a Penrose drain is used, the nurse changes the dressings as required. After these surgical procedures, the patient is observed for indications of infection, leakage of bile into the peritoneal cavity, and obstruction of bile drainage. If bile is not draining properly, an obstruction is probably causing bile to be forced back into the liver and bloodstream. Because jaundice may result, the nurse should be particularly observant of the color of the sclerae. The nurse should also note and report right upper quadrant abdominal pain, nausea and vomiting, bile drainage around any drainage tube, clay-colored stools, and a change in vital signs. Bile may continue to drain from the drainage tract in considerable quantities for a time, necessitating frequent changes of the outer dressings and protection of the skin from irritation because bile is corrosive to the skin. To prevent total loss of bile, the physician may want the drainage tube or collection receptacle elevated above the level of the abdomen so that the bile drains externally only if pressure develops in the duct system. Every 24 hours, the nurse measures the bile collected and records the amount, color, and character of the drainage. After several days of drainage, the tube may be clamped for an hour before and after each meal to deliver bile to the duodenum to aid in digestion. Within 7 to 14 days, the drainage tube is removed. The patient who goes home with a drainage tube in place requires instruction and reassurance about its function and care of the tube. In all patients with biliary drainage, the nurse observes the stools daily and notes their color. Specimens of both urine and stool may be sent to the laboratory for examination for bile pigments. In this way, it is possible to determine whether the bile pigment is disappearing from the blood and is draining again into the duodenum. Maintaining a careful record of fluid intake and output is important. IMPROVING NUTRITIONAL STATUS The nurse encourages the patient to eat a diet low in fats and high in carbohydrates and proteins immediately after surgery. At the time of hospital discharge, there are usually no special dietary instructions other than to maintain a nutritious diet and avoid excessive fats. Fat restriction usually is lifted in 4 to 6 weeks when
the biliary ducts dilate to accommodate the volume of bile once held by the gallbladder and when the ampulla of Vater again functions effectively. After this, when the patient eats fat, adequate bile will be released into the digestive tract to emulsify the fats and allow their digestion. This is in constrast to before surgery, when fats may not be digested completely or adequately, and flatulence may occur. However, one purpose of gallbladder surgery is to allow a normal diet. MONITORING AND MANAGING POTENTIAL COMPLICATIONS Bleeding may occur as a result of inadvertent puncture or nicking of a major blood vessel. Postoperatively, the nurse closely monitors vital signs and inspects the surgical incisions and drains, if in place, for evidence of bleeding. The nurse also periodically assesses the patient for increased tenderness and rigidity of the abdomen. If these signs and symptoms occur, they are reported to the surgeon. The nurse instructs the patient and family to report to the surgeon any change in the color of stools because this may indicate complications. Gastrointestinal symptoms, although not common, may occur with manipulation of the intestines during surgery. After laparoscopic cholecystectomy, the nurse assesses the patient for loss of appetite, vomiting, pain, distention of the abdomen, and temperature elevation. These may indicate infection or disruption of the gastrointestinal tract and should be reported to the surgeon promptly. Because the patient is discharged soon after laparoscopic surgery, the patient and family are instructed verbally and in writing about the importance of reporting these symptoms promptly. PROMOTING HOME AND COMMUNITY-BASED CARE Teaching Patients Self-Care The nurse instructs the patient about the medications that are prescribed (vitamins, anticholinergics, and antispasmodics) and their actions. It also is important to inform the patient and family about symptoms that should be reported to the physician, including jaundice, dark urine, pale-colored stools, pruritus, or signs of inflammation and infection, such as pain or fever. Some patients report one to three bowel movements a day. This is the result of a continual trickle of bile through the choledochoduodenal junction after cholecystectomy. Usually, such frequency diminishes over a period of a few weeks to several months. If a patient is discharged from the hospital with a drainage tube still in place, the patient and family may need instructions about its management. The nurse instructs them in proper care of the drainage tube and the importance of reporting to the physician promptly any changes in the amount or characteristics of drainage. Assistance in securing the appropriate dressings will reduce the patient’s anxiety about going home with the drain or tube still in place. (See Chart 40-3 for more details.) Continuing Care With sufficient support at home, most patients recover quickly from cholecystectomy. However, elderly or frail patients and those who live alone may require a referral for home care. During home visits, the nurse assesses the patient’s physical status, especially wound healing, and progress toward recovery. Assessing the patient for adequacy of pain relief and pulmonary exercises also is important. If the patient has a drainage system in place, the nurse assesses it for patency and appropriate management by the patient and family. Assessing for signs of infection and teaching the patient about
Chapter 40
Assessment and Management of Patients With Biliary Disorders
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Chart 40-3
• PATIENT EDUCATION Managing Self-Care After Laparoscopic Cholecystectomy Resuming Activity • Begin light exercise (walking) immediately. • Take a shower or bath after 1 or 2 days. • Drive a car after 3 or 4 days. • Avoid lifting objects exceeding 5 pounds after surgery, usually for 1 week. • Resume sexual activity when desired. Caring for the Wound • Check puncture site daily for signs of infection. • Wash puncture site with mild soap and water. • Allow special adhesive strips on the puncture site to fall off. Do not pull them off. Resuming Eating • Resume your normal diet. • If you had fat intolerance before surgery, gradually add fat back into your diet in small increments.
the signs and symptoms of infection are also important nursing interventions. The patient’s understanding of the therapeutic regimen (medications, gradual return to normal activities) is assessed, and previous teaching is reinforced. The nurse emphasizes the importance of keeping follow-up appointments and reminds the patient and family of the importance of participating in health promotion activities and recommended health screening.
Evaluation EXPECTED PATIENT OUTCOMES Expected patient outcomes may include: 1. Reports decrease in pain a. Splints abdominal incision to decrease pain b. Avoids foods that cause pain c. Uses postoperative analgesia as prescribed 2. Demonstrates appropriate respiratory function a. Achieves full respiratory excursion, with deep inspiration and expiration b. Coughs effectively, using pillow to splint abdominal incision c. Uses postoperative analgesia as prescribed d. Exercises as prescribed (eg, turns, ambulates) 3. Exhibits normal skin integrity around biliary drainage site (if applicable) a. Is free of fever, abdominal pain, change in vital signs, or bile, foul-smelling drainage, or pus around drainage tube b. Demonstrates proper management of drainage tube (if applicable) c. Identifies signs and symptoms of biliary obstruction to be noted and reported d. Has serum bilirubin level within normal range 4. Obtains relief of dietary intolerance a. Maintains adequate dietary intake and avoids foods that cause gastrointestinal symptoms b. Reports decreased or absent nausea, vomiting, diarrhea, flatulence, and abdominal discomfort 5. Absence of complications a. Has normal vital signs (blood pressure, pulse, respiratory rate and pattern, and temperature)
Managing Pain • You may experience pain or discomfort in your right shoulder from the gas used to inflate your abdominal area during surgery. Sitting upright in bed or a chair or walking may ease the discomfort. Managing Follow-Up Care • Make an appointment with your surgeon for 7 to 10 days after discharge. • Call your surgeon if you experience any signs or symptoms of infection at or around the puncture site: redness, tenderness, swelling, heat, or drainage. • Call your surgeon if you experience a fever of 37.7°C (100°F) or more for 2 consecutive days. • Call your surgeon if you develop nausea, vomiting, or abdominal pain.
b. Reports absence of bleeding from gastrointestinal tract, biliary drainage tube/catheter (if present) and no evidence of bleeding in stool c. Reports return of appetite and no evidence of vomiting, abdominal distention, and pain d. Lists symptoms that should be reported to surgeon promptly and demonstrates an understanding of selfcare, including wound care
Disorders of the Pancreas Pancreatitis (inflammation of the pancreas) is a serious disorder. The most basic classification system used to describe or categorize the various stages and forms of pancreatitis divides the disorder into acute or chronic forms. Acute pancreatitis can be a medical emergency associated with a high risk for life-threatening complications and mortality, whereas chronic pancreatitis often goes undetected until 80% to 90% of the exocrine and endocrine tissue is destroyed. Acute pancreatitis does not usually lead to chronic pancreatitis unless complications develop. However, chronic pancreatitis can be characterized by acute episodes. Typically, patients are men 40 to 45 years of age with a history of alcoholism or women 50 to 55 years of age with a history of biliary disease (Hale et al., 2000). Although the mechanisms causing pancreatic inflammation are unknown, pancreatitis is commonly described as autodigestion of the pancreas. Generally, it is believed that the pancreatic duct becomes obstructed, accompanied by hypersecretion of the exocrine enzymes of the pancreas. These enzymes enter the bile duct, where they are activated and, together with bile, back up (reflux) into the pancreatic duct, causing pancreatitis.
ACUTE PANCREATITIS Acute pancreatitis ranges from a mild, self-limiting disorder to a severe, rapidly fatal disease that does not respond to any treatment. Mild acute pancreatitis is characterized by edema and inflammation confined to the pancreas. Minimal organ dysfunction is present, and return to normal usually occurs within 6 months. Although this is considered the milder form of pancreatitis, the
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patient is acutely ill and at risk for hypovolemic shock, fluid and electrolyte disturbances, and sepsis. A more widespread and complete enzymatic digestion of the gland characterizes severe acute pancreatitis. The tissue becomes necrotic, and the damage extends into the retroperitoneal tissues. Local complications consist of pancreatic cysts or abscesses and acute fluid collections in or near the pancreas. Systemic complications, such as acute respiratory distress syndrome, shock, disseminated intravascular coagulopathy, and pleural effusion, can increase the mortality rate to 50% or higher (Aronson, 1999). Gerontologic Considerations Acute pancreatitis affects people of all ages, but the mortality rate associated with acute pancreatitis increases with advancing age. In addition, the pattern of complications changes with age. Younger patients tend to develop local complications; the incidence of multiple organ failure increases with age, possibly as a result of progressive decreases in physiologic function of major organs with increasing age. Close monitoring of major organ function (ie, lungs, kidneys) is essential, and aggressive treatment is necessary to reduce mortality from acute pancreatitis in the elderly.
Pathophysiology Self-digestion of the pancreas by its own proteolytic enzymes, principally trypsin, causes acute pancreatitis. Eighty percent of patients with acute pancreatitis have biliary tract disease; however, only 5% of patients with gallstones develop pancreatitis. Gallstones enter the common bile duct and lodge at the ampulla of Vater, obstructing the flow of pancreatic juice or causing a reflux of bile from the common bile duct into the pancreatic duct, thus activating the powerful enzymes within the pancreas. Normally, these remain in an inactive form until the pancreatic secretions reach the lumen of the duodenum. Activation of the enzymes can lead to vasodilation, increased vascular permeability, necrosis, erosion, and hemorrhage (Quillen, 2001). Long-term use of alcohol is commonly associated with acute episodes of pancreatitis, but the patient usually has had undiagnosed chronic pancreatitis before the first episode of acute pancreatitis occurs. Other less common causes of pancreatitis include bacterial or viral infection, with pancreatitis a complication of mumps virus. Spasm and edema of the ampulla of Vater, resulting from duodenitis, can probably produce pancreatitis. Blunt abdominal trauma, peptic ulcer disease, ischemic vascular disease, hyperlipidemia, hypercalcemia, and the use of corticosteroids, thiazide diuretics, and oral contraceptives also have been associated with an increased incidence of pancreatitis. Acute pancreatitis may follow surgery on or near the pancreas or after instrumentation of the pancreatic duct. Acute idiopathic pancreatitis accounts for up to 20% of the cases of acute pancreatitis (Hale, Moseley & Warner, 2000). In addition, there is a small incidence of hereditary pancreatitis. The mortality rate of patients with acute pancreatitis is high (10%) because of shock, anoxia, hypotension, or fluid and electrolyte imbalances. Attacks of acute pancreatitis may result in complete recovery, may recur without permanent damage, or may progress to chronic pancreatitis. The patient admitted to the hospital with a diagnosis of pancreatitis is acutely ill and needs expert nursing and medical care. Severity and mortality predictions of acute alcoholic pancreatitis are generally assessed using Ranson’s criteria (Tierney,
McPhee & Papadakis, 2001). The Acute Physiology and Chronic Health Evaluation (APACHE) grading system may also be used. Predictors of the severity of pancreatitis and its prognosis are listed in Chart 40-4.
Clinical Manifestations Severe abdominal pain is the major symptom of pancreatitis that causes the patient to seek medical care. Abdominal pain and tenderness and back pain result from irritation and edema of the inflamed pancreas that stimulate the nerve endings. Increased tension on the pancreatic capsule and obstruction of the pancreatic ducts also contribute to the pain. Typically, the pain occurs in the midepigastrium. Pain is frequently acute in onset, occurring 24 to 48 hours after a very heavy meal or alcohol ingestion, and it may be diffuse and difficult to localize. It is generally more severe after meals and is unrelieved by antacids. Pain may be accompanied by abdominal distention; a poorly defined, palpable abdominal mass; and decreased peristalsis. Pain caused by pancreatitis is accompanied frequently by vomiting that does not relieve the pain or nausea. The patient appears acutely ill. Abdominal guarding is present. A rigid or board-like abdomen may develop and is generally an ominous sign; the abdomen may remain soft in the absence of peritonitis. Ecchymosis (bruising) in the flank or around the umbilicus may indicate severe pancreatitis. Nausea and vomiting are common in acute pancreatitis. The emesis is usually gastric in origin but may also be bile-stained. Fever, jaundice, mental confusion, and agitation also may occur. Hypotension is typical and reflects hypovolemia and shock caused by the loss of large amounts of protein-rich fluid into the tissues and peritoneal cavity. The patient may develop tachycardia, cyanosis, and cold, clammy skin in addition to hypotension. Acute renal failure is common. Respiratory distress and hypoxia are common, and the patient may develop diffuse pulmonary infiltrates, dyspnea, tachypnea, and abnormal blood gas values. Myocardial depression, hypocalcemia, hyperglycemia, and disseminated intravascular coagulopathy (DIC) may also occur with acute pancreatitis.
Chart 40-4
Criteria for Predicting Severity of Pancreatitis*
Criteria on Admission to Hospital Age >55 years WBC >16,000 mm3 Serum glucose >200 mg/dL (>11.1 mmol/L) Serum LDH >350 IU/L (>350 U/L) AST >250 U/mL (120 U/L) Criteria Within 48 Hours of Hospital Admission Fall in hematocrit >10% (>0.10) BUN increase >5 mg/dL (>1.7 mmol/L) Serum calcium 4 mmol/L) Fluid retention or sequestration >6 L PO2 6 signs: 100% mortality. *Note: The more risk factors a patient has, the greater the severity and the greater the likelihood of a complicated course or death.
Chapter 40
Assessment and Management of Patients With Biliary Disorders
Assessment and Diagnostic Findings The diagnosis of acute pancreatitis is based on a history of abdominal pain, the presence of known risk factors, physical examination findings, and diagnostic findings. Serum amylase and lipase levels are used in making the diagnosis of acute pancreatitis. In 90% of the cases, serum amylase and lipase levels usually rise in excess of three times their normal upper limit within 24 hours (Tierney, McPhee & Papadakis, 2001). Serum amylase usually returns to normal within 48 to 72 hours. Serum lipase levels may remain elevated for 7 to 14 days (Braunwald et al., 2001). Urinary amylase levels also become elevated and remain elevated longer than serum amylase levels. The white blood cell count is usually elevated; hypocalcemia is present in many patients and correlates well with the severity of pancreatitis. Transient hyperglycemia and glucosuria and elevated serum bilirubin levels occur in some patients with acute pancreatitis. X-ray studies of the abdomen and chest may be obtained to differentiate pancreatitis from other disorders that may cause similar symptoms and to detect pleural effusions. Ultrasound and contrast-enhanced computed tomography scans are used to identify an increase in the diameter of the pancreas and to detect pancreatic cysts, abscesses, or pseudocysts. Hematocrit and hemoglobin levels are used to monitor the patient for bleeding. Peritoneal fluid, obtained through paracentesis or peritoneal lavage, may contain increased levels of pancreatic enzymes. The stools of patients with pancreatic disease are often bulky, pale, and foul-smelling. Fat content of stools varies between 50% and 90% in pancreatic disease; normally, the fat content is 20%. ERCP is rarely used in the diagnostic evaluation of acute pancreatitis because the patient is acutely ill; however, it may be valuable in the treatment of gallstone pancreatitis.
unit, where hemodynamic monitoring and arterial blood gas monitoring are initiated. Antibiotic agents may be prescribed if infection is present; insulin may be required if significant hyperglycemia occurs. RESPIRATORY CARE Aggressive respiratory care is indicated because of the high risk for elevation of the diaphragm, pulmonary infiltrates and effusion, and atelectasis. Hypoxemia occurs in a significant number of patients with acute pancreatitis even with normal x-ray findings. Respiratory care may range from close monitoring of arterial blood gases to use of humidified oxygen to intubation and mechanical ventilation (see Chap. 25 for further discussion). BILIARY DRAINAGE Placement of biliary drains (for external drainage) and stents (indwelling tubes) in the pancreatic duct through endoscopy has been performed to reestablish drainage of the pancreas. This has resulted in decreased pain and increased weight gain. SURGICAL INTERVENTION Although often risky because the acutely ill patient is a poor surgical risk, surgery may be performed to assist in the diagnosis of pancreatitis (diagnostic laparotomy), to establish pancreatic drainage, or to resect or débride a necrotic pancreas. The patient who undergoes pancreatic surgery may have multiple drains in place postoperatively as well as a surgical incision that is left open for irrigation and repacking every 2 to 3 days to remove necrotic debris (Fig. 40-6).
Medical Management Management of the patient with acute pancreatitis is directed toward relieving symptoms and preventing or treating complications. All oral intake is withheld to inhibit pancreatic stimulation and secretion of pancreatic enzymes. Parenteral nutrition is usually an important part of therapy, particularly in debilitated patients, because of the extreme metabolic stress associated with acute pancreatitis (Dejong, Greve & Soeters, 2001). Nasogastric suction may be used to relieve nausea and vomiting, to decrease painful abdominal distention and paralytic ileus, and to remove hydrochloric acid so that it does not enter the duodenum and stimulate the pancreas. Histamine-2 (H2) antagonists (eg, cimetidine [Tagamet] and ranitidine [Zantac]) may be prescribed to decrease pancreatic activity by inhibiting HCl secretion. PAIN MANAGEMENT Adequate pain medication is essential during the course of acute pancreatitis to provide sufficient pain relief and minimize restlessness, which may stimulate pancreatic secretion further. Morphine and morphine derivatives are often avoided because it has been thought that they cause spasm of the sphincter of Oddi; meperidine (Demerol) is often prescribed because it is less likely to cause spasm of the sphincter (Porth, 2002). Antiemetic agents may be prescribed to prevent vomiting. INTENSIVE CARE Correction of fluid and blood loss and low albumin levels is necessary to maintain fluid volume and prevent renal failure. The patient is usually acutely ill and is monitored in the intensive care
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Nasogastric tube
Irrigation tubing
Incision
Air vent
To suction
Drainage tubing
FIGURE 40-6 Multiple sump tubes are used after pancreatic surgery. Triple-lumen tubes consist of ports that provide tubing for irrigation, air venting, and drainage.
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POSTACUTE MANAGEMENT Antacids may be used when acute pancreatitis begins to resolve. Oral feedings low in fat and protein are initiated gradually. Caffeine and alcohol are eliminated from the diet. If the episode of pancreatitis occurred during treatment with thiazide diuretics, corticosteroids, or oral contraceptives, these medications are discontinued. Follow-up of the patient may include ultrasound, x-ray studies, or ERCP to determine whether the pancreatitis is resolving and to assess for abscesses and pseudocysts. ERCP may also be used to identify the cause of acute pancreatitis if it is in question and for endoscopic sphincterotomy and removal of gallstones from the common bile duct.
NURSING PROCESS: THE PATIENT WITH ACUTE PANCREATITIS Assessment The health history focuses on the presence and character of the abdominal pain and discomfort. The nurse assesses the presence of pain, its location, its relationship to eating and to alcohol consumption, and the effectiveness of pain relief measures. It also is important to assess the patient’s nutritional and fluid status and history of gallbladder attacks and alcohol use. A history of gastrointestinal problems, including nausea, vomiting, diarrhea, and passage of fatty stools, is elicited. The nurse assesses the abdomen for pain, tenderness, guarding, and bowel sounds, noting the presence of a board-like or soft abdomen. It also is important to assess respiratory status, respiratory rate and pattern, and breath sounds. Normal and adventitious breath sounds and abnormal findings on chest percussion, including dullness at the bases of the lungs and abnormal tactile fremitus, are documented. The nurse assesses the emotional and psychological status of the patient and family and their coping, because they are often anxious about the severity of the symptoms and the acuity of illness.
Diagnosis NURSING DIAGNOSES Based on all the assessment data, the major nursing diagnoses of the patient with acute pancreatitis include the following: • Acute pain related to inflammation, edema, distention of the pancreas, and peritoneal irritation • Ineffective breathing pattern related to severe pain, pulmonary infiltrates, pleural effusion, atelectasis, and elevated diaphragm • Imbalanced nutrition, less than body requirements, related to reduced food intake and increased metabolic demands • Impaired skin integrity related to poor nutritional status, bed rest, and multiple drains and surgical wound COLLABORATIVE PROBLEMS/ POTENTIAL COMPLICATIONS Based on assessment data, potential complications that may occur include the following: • Fluid and electrolyte disturbances • Necrosis of the pancreas • Shock and multiple organ dysfunction
Planning and Goals The major goals for the patient include relief of pain and discomfort, improved respiratory function, improved nutritional status, maintenance of skin integrity, and absence of complications.
Nursing Interventions RELIEVING PAIN AND DISCOMFORT Because the pathologic process responsible for pain is autodigestion of the pancreas, the objectives of therapy are to relieve pain and decrease secretion of the enzymes of the pancreas. The pain of acute pancreatitis is often very severe, necessitating the liberal use of analgesic agents. Meperidine (Demerol) is the medication of choice; morphine sulfate is avoided because it causes spasm of the sphincter of Oddi (Porth, 2002). Oral feedings are withheld to decrease the formation and secretion of secretin. The patient is maintained on parenteral fluids and electrolytes to restore and maintain fluid balance. Nasogastric suction is used to remove gastric secretions and to relieve abdominal distention. The nurse provides frequent oral hygiene and care to decrease discomfort from the nasogastric tube and relieve dryness of the mouth. The acutely ill patient is maintained on bed rest to decrease the metabolic rate and reduce the secretion of pancreatic and gastric enzymes. If the patient experiences increasing severity of pain, the nurse reports this to the physician because the patient may be experiencing hemorrhage of the pancreas, or the dose of analgesic may be inadequate. The patient with acute pancreatitis often has a clouded sensorium because of severe pain, fluid and electrolyte disturbances, and hypoxia. Therefore, the nurse provides frequent and repeated but simple explanations about the need for withholding fluid intake and about maintenance of gastric suction and bed rest. IMPROVING BREATHING PATTERN The nurse maintains the patient in a semi-Fowler’s position to decrease pressure on the diaphragm by a distended abdomen and to increase respiratory expansion. Frequent changes of position are necessary to prevent atelectasis and pooling of respiratory secretions. Pulmonary assessment and monitoring of pulse oximetry or arterial blood gases are essential to detect changes in respiratory status so that early treatment can be initiated. The nurse instructs the patient in techniques of coughing and deep breathing to improve respiratory function and encourages and assists the patient to cough and deep breathe every 2 hours. IMPROVING NUTRITIONAL STATUS The patient with acute pancreatitis is not permitted food and oral fluid intake; however, it is important to assess the patient’s nutritional status and to note factors that alter the patient’s nutritional requirements (eg, temperature elevation, surgery, drainage). Laboratory test results and daily weights are useful in monitoring the nutritional status. Parenteral nutrition may be prescribed. In addition to administering parenteral nutrition, the nurse monitors serum glucose levels every 4 to 6 hours. As the acute symptoms subside, the nurse gradually reintroduces oral feedings. Between acute attacks, the patient receives a diet high in carbohydrates and low in fat and proteins. The patient should avoid heavy meals and alcoholic beverages. IMPROVING SKIN INTEGRITY The patient is at risk for skin breakdown because of poor nutritional status, enforced bed rest, and restlessness, which may result in pressure ulcers and breaks in tissue integrity. In addition, the patient who has undergone surgery, has had multiple drains inserted, or has an open surgical incision is at risk for skin breakdown and infection. The nurse carefully assesses the wound,
Chapter 40
Assessment and Management of Patients With Biliary Disorders
drainage sites, and skin for signs of infection, inflammation, and breakdown. The nurse carries out wound care as prescribed and takes precautions to protect intact skin from contact with drainage. Consultation with an enterostomal therapist is often helpful in identifying appropriate skin care devices and protocols. It is important to turn the patient every 2 hours; use of specialty beds may be indicated to prevent skin breakdown. MONITORING AND MANAGING POTENTIAL COMPLICATIONS Fluid and electrolyte disturbances are common complications because of nausea, vomiting, movement of fluid from the vascular compartment to the peritoneal cavity, diaphoresis, fever, and the use of gastric suction. The nurse assesses the patient’s fluid and electrolyte status by noting skin turgor and moistness of mucous membranes. The nurse weighs the patient daily and carefully measures fluid intake and output, including urine output, nasogastric secretions, and diarrhea. In addition, it is important to assess the patient for other factors that may affect fluid and electrolyte status, including increased body temperature and wound drainage. The nurse assesses the patient for ascites and measures abdominal girth daily if ascites is suspected. Intravenous fluids are administered and may be accompanied by infusion of blood, blood products, and albumin to maintain the blood volume and to prevent or treat hypovolemic shock. It is important to keep emergency medications readily available because of the risk of circulatory collapse and shock. The nurse promptly reports decreased blood pressure and reduced urine output because they may indicate hypovolemia and shock or renal failure. Low serum calcium and magnesium levels may occur and require prompt treatment. Pancreatic necrosis is a major cause of morbidity and mortality in patients with acute pancreatitis. The patient who develops necrosis is at risk for hemorrhage, septic shock, and multiple organ failure. The patient may undergo diagnostic procedures to confirm pancreatic necrosis; surgical débridement or insertion of multiple drains may be performed. The patient with pancreatic necrosis is usually critically ill and requires expert medical and nursing management, including hemodynamic monitoring in the intensive care unit. In addition to carefully monitoring vital signs and other signs and symptoms, the nurse is responsible for administering prescribed fluids, medications, and blood products; assisting with supportive management, such as use of a ventilator; preventing additional complications; and attending to the patient’s physical and psychological care. Shock and multiple organ failure may occur with acute pancreatitis. Hypovolemic shock may occur as a result of hypovolemia and sequestering of fluid in the peritoneal cavity. Hemorrhagic shock may occur with hemorrhagic pancreatitis. Septic shock may occur with bacterial infection of the pancreas. Cardiac dysfunction may occur as a result of fluid and electrolyte disturbances, acid–base imbalances, and release of toxic substances into the circulation. The nurse closely monitors the patient for early signs of neurologic, cardiovascular, renal, and respiratory dysfunction. The nurse must be prepared to respond quickly to rapid changes in the patient’s status, treatments, and therapies. In addition, it is important to inform the family about the status and progress of the patient and allow them to spend time with the patient. (Management of the patient in shock is discussed in detail in Chap. 15.)
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PROMOTING HOME AND COMMUNITY-BASED CARE Teaching Patients Self-Care The patient who has survived an episode of acute pancreatitis has been acutely ill. A prolonged period is needed to regain strength and return to previous level of activity. The patient is often still weak and debilitated weeks or months after an acute episode of pancreatitis. Because of the severity of the acute illness, the patient may not recall many of the explanations and instructions given during the acute phase, so these often need to be repeated and reinforced. The nurse instructs the patient about the factors implicated in the onset of acute pancreatitis and about the need to avoid high-fat foods, heavy meals, and alcohol. It is important to give the patient and family verbal and written instructions about signs and symptoms of acute pancreatitis and possible complications that should be reported promptly to the physician. If acute pancreatitis is a result of biliary tract disease, such as gallstones and gallbladder disease, additional explanations are needed about required dietary modifications. If the pancreatitis is a result of alcohol abuse, the nurse reminds the patient of the importance of eliminating all alcohol. Continuing Care A referral for home care often is indicated; this enables the nurse to assess the patient’s physical and psychological status and adherence to the therapeutic regimen. The nurse also assesses the home situation and reinforces instructions about fluid and nutrition intake and avoidance of alcohol. When the acute attack has subsided, some patients may be inclined to return to their previous drinking habits. The nurse provides specific information about resources and support groups that may be of assistance in avoiding alcohol in the future. Referral to Alcoholics Anonymous or other appropriate support groups is essential. A summary of nursing management of the patient with acute pancreatitis is provided in the Plan of Nursing Care.
Evaluation EXPECTED PATIENT OUTCOMES Expected patient outcomes may include: 1. Reports relief of pain and discomfort a. Uses analgesics and anticholinergics as prescribed, without overuse b. Maintains bed rest as prescribed c. Avoids alcohol to decrease abdominal pain 2. Experiences improved respiratory function a. Changes position in bed frequently b. Coughs and takes deep breaths at least every hour c. Demonstrates normal respiratory rate and pattern, full lung expansion, normal breath sounds d. Demonstrates normal body temperature and absence of respiratory infection 3. Achieves nutritional and fluid and electrolyte balance a. Reports decrease in number of episodes of diarrhea b. Identifies and consumes high-carbohydrate, low-protein foods c. Explains rationale for eliminating alcohol intake d. Maintains adequate fluid intake within prescribed guidelines e. Exhibits adequate urine output
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Plan of Nursing Care Care of the Patient With Acute Pancreatitis Nursing Interventions
Rationale
Expected Outcomes
Nursing Diagnosis: Acute pain and discomfort related to edema, distention of the pancreas, and peritoneal irritation Goal: Relief of pain and discomfort 1. Administer meperidine (Demerol) frequently, as prescribed, to achieve level of pain acceptable to patient based on patient’s level of pain and discomfort. 2. Using a pain scale, assess pain level before and after administration of analgesic.
3. Report unrelieved pain or increasing intensity of pain. 4. Assist the patient to assume positions of comfort; turn and reposition every 2 hours. 5. Use nonpharmacologic interventions for relieving pain (eg, relaxation, focused breathing, diversion). 6. Listen to patient’s expression of pain experience.
1. Meperidine acts by depressing the central nervous system and thereby increasing the patient’s pain threshold. Morphine is avoided because it produces spasm of the sphincter of Oddi. 2. Assessment and control of pain are important because restlessness increases body metabolism, which stimulates the secretion of pancreatic and gastric enzymes. 3. Pain may increase pancreatic enzymes and may also indicate pancreatic hemorrhage. 4. Frequent turning relieves pressure and assists in preventing pulmonary and vascular complications. 5. Use of nonpharmacologic methods will enhance the effects of analgesics. Gate control theory states that cutaneous stimulation closes the pain pathways. 6. Demonstration of caring can help to decrease anxiety.
• Reports relief of pain • Moves and turns without increasing pain and discomfort
• Rests comfortably and sleeps for increasing periods
• Reports less frequent episodes of pain, discomfort, and cramping
• Experiences enhanced pain relief • Reports increased feelings of well-being and security with the health care team
Goal: Relief of pain related to stimulation of the pancreas 1. Administer anticholinergic medications as prescribed. 2. Withhold oral intake. 3. Maintain the patient on bed rest. 4. Maintain continuous nasogastric drainage. a. Measure gastric secretions at specified intervals. b. Observe and record color and viscosity of gastric secretions. c. Ensure that the nasogastric tube is patent to permit free drainage.
1. Anticholinergic medications reduce gastric and pancreatic secretion. 2. Pancreatic secretion is increased by food and fluid intake. 3. Bed rest decreases body metabolism and thus reduces pancreatic and gastric secretions. 4. Nasogastric suction removes gastric contents and prevents gastric secretions from entering the duodenum and stimulating the secretin mechanism. Decompression of the intestines (if intestinal intubation is used) also assists in relieving respiratory distress.
• Reports relief of pain, discomfort, and abdominal cramping
• Consumes no fluid and food during acute phase
• Maintains bed rest • Identifies rationale for fluid and dietary restrictions and use of nasogastric drainage
• Cooperates with insertion of nasogastric tube and suction
Nursing Diagnosis: Discomfort related to nasogastric tube Goal: Relief of discomfort associated with nasogastric intubation 1. Use water-soluble lubricant around external nares. 2. Turn patient at intervals; avoid pressure or tension on nasogastric tube 3. Provide oral hygiene and gargling solutions without alcohol. 4. Explain rationale for use of nasogastric drainage.
1. Prevents irritation of nares
• Exhibits intact skin and tissue of nares at
2. Relieves pressure of tube on esophageal and gastric mucosa 3. Relieves dryness and irritation of oropharynx 4. Assists patient to cooperate with the drainage, nasogastric tube, and suction.
• Reports no pain or irritation of nares or
site of nasogastric tube insertion oropharynx
• Exhibits moist, clean mucous membranes of mouth and nasopharynx
• States that thirst is relieved by oral hygiene • Identifies rationale for nasogastric tube and suction
(continued)
Chapter 40
Assessment and Management of Patients With Biliary Disorders
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Plan of Nursing Care Care of the Patient With Acute Pancreatitis (Continued) Nursing Interventions
Rationale
Expected Outcomes
Nursing Diagnosis: Imbalanced nutrition: less than body requirements related to inadequate dietary intake, impaired pancreatic secretions, increased nutritional needs secondary to acute illness, and increased body temperature Goal: Improvement in nutritional status 1. Assess current nutritional status and increased metabolic requirements. 2. Monitor serum glucose levels and administer insulin as prescribed. 3. Administer intravenous fluid and electrolytes and parenteral nutrition as prescribed. 4. Provide high-carbohydrate, low-protein, low-fat diet when tolerated. 5. Instruct patient to eliminate alcohol and refer to Alcoholics Anonymous if indicated. 6. Counsel patient to avoid excessive use of coffee and spicy foods. 7. Monitor daily weights.
1. Alteration in pancreatic secretions interferes with normal digestive processes. Acute illness, infection, and fever increase metabolic needs. 2. Impairment of endoctrine function of the pancreas leads to increased serum glucose levels. 3. Parenteral administration of fluids, electrolytes, and nutrients is essential to provide fluids, calories, electrolytes, and nutrients when oral intake is prohibited. 4. These foods increase caloric intake without stimulating pancreatic secretions beyond the ability of the pancreas to respond. 5. Alcohol intake produces further damage to pancreas and precipitates attacks of acute pancreatitis. 6. Coffee and spicy foods increase pancreatic and gastric secretions. 7. This provides a baseline and a means to measure desirable weight.
• • • •
Maintains normal body weight Demonstrates no additional weight loss Maintains normal serum glucose levels Reports decreasing episodes of vomiting and diarrhea • Reports return of normal stool characteristics and bowel pattern • Consumes foods high in carbohydrate, low in fat and protein • Explains rationale for high-carbohydrate, low-fat, low-protein diet • Eliminates alcohol from diet • Explains rationale for limiting coffee intake and avoiding spicy foods • Participates in Alcoholics Anonymous or other counseling approach • Returns to and maintains desirable weight
Nursing Diagnosis: Ineffective breathing pattern related to splinting from severe pain, pulmonary infiltrates, pleural effusion, and atelectasis Goal: Improvement in respiratory function 1. Assess respiratory status (rate, pattern, breath sounds), pulse oximetry, and arterial blood gases.
2. Maintain semi-Fowler’s position. 3. Instruct and encourage patient to take deep breaths and to cough every hour. 4. Assist patient to turn and change position every 2 hours. 5. Reduce the excessive metabolism of the body. a. Administer antibiotics as prescribed. b. Place patient in an air-conditioned room. c. Administer nasal oxygen as required for hypoxia. d. Use a hypothermia blanket if necessary.
1. Acute pancreatitis produces retroperitoneal edema, elevation of the diaphragm, pleural effusion, and inadequate lung ventilation. Intra-abdominal infection and labored breathing increase the body’s metabolic demands, which further decreases pulmonary reserve and leads to respiratory failure. 2. Decreases pressure on diaphragm and allows greater lung expansion. 3. Taking deep breaths and coughing will clear the airways and reduce atelectasis. 4. Changing position frequently assists aeration and drainage of all lobes of the lungs. 5. Pancreatitis produces a severe peritoneal and retroperitoneal reaction that causes fever, tachycardia, and accelerated respirations. Placing the patient in an airconditioned room and supporting the patient with oxygen therapy decrease the workload of the respiratory system and the tissue utilization of oxygen. Reduction of fever and pulse rate decreases the metabolic demands on the body.
• Demonstrates normal respiratory rate and pattern and full lung expansion
• Demonstrates normal breath sounds and absence of adventitious breath sounds
• Demonstrates normal arterial blood gases and pulse oximetry
• Maintains semi-Fowler’s position when in bed
• Changes position in bed frequently • Coughs and takes deep breaths at least every hour
• Demonstrates normal body temperature • Exhibits no signs or symptoms of respiratory infection or impairment
• Is alert and responsive to environment
(continued)
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Unit 8
METABOLIC AND ENDOCRINE FUNCTION
Plan of Nursing Care Care of the Patient With Acute Pancreatitis (Continued) Nursing Interventions
Rationale
Expected Outcomes
Collaborative Problem: Fluid and electrolyte disturbances, hypovolemia, shock Goal: Improvement in fluid and electrolyte status, prevention of hypovolemia and shock 1. Assess fluid and electrolyte status (skin turgor, mucous membranes, urine output, vital signs, hemodynamic parameters).
2. Assess sources of fluid and electrolyte loss (vomiting, diarrhea, nasogastric drainage, excessive diaphoresis). 3. Combat shock if present. a. Administer corticosteroids as prescribed if patient does not respond to conventional treatment. b. Evaluate the amount of urinary output. Attempt to maintain this at 50 mL/h. 4. Administer blood products, fluids, and electrolytes (sodium, potassium, chloride) as prescribed. 5. Administer plasma, albumin, and blood products as prescribed. 6. Keep a supply of intravenous calcium gluconate readily available. 7. Assess abdomen for ascites formation: a. Measure abdominal girth daily. b. Weigh patient daily. c. Palpate abdomen for fluid wave. 8. Monitor for manifestations of multiple organ failure: neurologic, cardiovascular, renal, and respiratory dysfunction.
1. The amount and type of fluid and electrolyte replacement are determined by the status of the blood pressure, the laboratory evaluations of serum electrolyte and blood urea nitrogen levels, the urinary volume, and the assessment of the patient’s condition. 2. Electrolyte losses occur from nasogastric suctioning, severe diaphoresis, emesis, and as a result of the patient’s being in a fasting state. 3. Extensive acute pancreatitis may cause peripheral vascular collapse and shock. Blood and plasma may be lost into the abdominal cavity, and, therefore, there is a decreased blood and plasma volume. The toxins from the bacteria of a necrotic pancreas may cause shock. 4. Patients with hemorrhagic pancreatitis lose large amounts of blood and plasma, which decreases effective circulation and blood volume. 5. Replacement with blood, plasma or albumin assists in ensuring effective circulating blood volume. 6. Calcium may be prescribed to prevent or treat tetany. 7. During acute pancreatitis, plasma may be lost into the abdominal cavity, which diminishes the blood volume.
• Exhibits moist mucous membranes and normal skin turgor
• Exhibits normal blood pressure without • • • • • • • • • • • •
evidence of postural (orthostatic) hypotension Excretes adequate urine volume Exhibits normal, not excessive, thirst Maintains normal pulse and respiratory rate Remains alert and responsive Exhibits normal arterial pressures and blood gases Exhibits normal electrolyte levels Exhibits no signs or symptoms of calcium deficit (eg, tetany, carpopedal spasm) Exhibits no additional losses of fluids and electrolytes through vomiting, diarrhea, or diaphoresis Reports stabilization of weight Demonstrates no increase in abdominal girth Demonstrates no fluid wave on palpation of the abdomen Demonstrates stable organ function without manifestations of failure
8. All body systems may fail if pancreatitis is severe and treatment is ineffective.
4. Exhibits intact skin a. Skin is without breakdown or infection b. Drainage is contained adequately 5. Absence of complications a. Demonstrates normal skin turgor, moist mucous membranes, normal serum electrolyte levels b. Exhibits stabilization of weight, with no increase in abdominal girth c. Exhibits normal neurologic, cardiovascular, renal, and respiratory function
CHRONIC PANCREATITIS Chronic pancreatitis is an inflammatory disorder characterized by progressive anatomic and functional destruction of the pancreas. As cells are replaced by fibrous tissue with repeated attacks of pancreatitis, pressure within the pancreas increases. The end result is mechanical obstruction of the pancreatic and common bile ducts and the duodenum. Additionally, there is atrophy of the epithe-
lium of the ducts, inflammation, and destruction of the secreting cells of the pancreas. Alcohol consumption in Western societies and malnutrition worldwide are the major causes of chronic pancreatitis. Excessive and prolonged consumption of alcohol accounts for approximately 70% of the cases (Clain & Pearson, 1999). The incidence of pancreatitis is 50 times greater in alcoholics than in the nondrinking population. Long-term alcohol consumption causes hypersecretion of protein in pancreatic secretions, resulting in protein plugs and calculi within the pancreatic ducts. Alcohol also has a direct toxic effect on the cells of the pancreas. Damage to these cells is more likely to occur and to be more severe in patients whose diets are poor in protein content and either very high or very low in fat.
Clinical Manifestations Chronic pancreatitis is characterized by recurring attacks of severe upper abdominal and back pain, accompanied by vomiting. Attacks are often so painful that opioids, even in large doses, do
Chapter 40
Assessment and Management of Patients With Biliary Disorders
not provide relief. As the disease progresses, recurring attacks of pain are more severe, more frequent, and of longer duration. Some patients experience continuous severe pain; others have a dull, nagging constant pain. The risk of dependence on opioids is increased in pancreatitis because of the chronic nature and severity of the pain. Weight loss is a major problem in chronic pancreatitis: more than 75% of patients experience significant weight loss, usually caused by decreased dietary intake secondary to anorexia or fear that eating will precipitate another attack. Malabsorption occurs late in the disease, when as little as 10% of pancreatic function remains. As a result, digestion, especially of proteins and fats, is impaired. The stools become frequent, frothy, and foul-smelling because of impaired fat digestion, which results in stools with a high fat content. This is referred to as steatorrhea. As the disease progresses, calcification of the gland may occur, and calcium stones may form within the ducts.
Assessment and Diagnostic Findings ERCP is the most useful study in the diagnosis of chronic pancreatitis. It provides detail about the anatomy of the pancreas and the pancreatic and biliary ducts. It is also helpful in obtaining tissue for analysis and differentiating pancreatitis from other conditions, such as carcinoma. Various imaging procedures, including magnetic resonance imaging, computed tomography, and ultrasound, have been useful in the diagnostic evaluation of patients with suspected pancreatic disorders. Computed tomography scanning or ultrasound is helpful to detect pancreatic cysts. A glucose tolerance test evaluates pancreatic islet cell function, information necessary for making decisions about surgical resection of the pancreas. An abnormal glucose tolerance test indicative of diabetes may be present. In contrast to the patient with acute pancreatitis, serum amylase levels and the white blood cell count may not be elevated significantly.
Medical Management The management of chronic pancreatitis depends on its probable cause in each patient. Treatment is directed toward preventing and managing acute attacks, relieving pain and discomfort, and managing exocrine and endocrine insufficiency of pancreatitis. NONSURGICAL MANAGEMENT Nonsurgical approaches may be indicated for the patient who refuses surgery, who is a poor surgical risk, or whose disease and symptoms do not warrant surgical intervention. Endoscopy to remove pancreatic duct stones and stent strictures may be effective in selected patients to manage pain and relieve obstruction. However, such therapy is available only in special centers and is suitable for few patients (Bornman & Beckingham, 2001). Management of abdominal pain and discomfort is similar to that of acute pancreatitis; however, the focus is usually on the use of nonopioid methods to manage pain. Persistent, unrelieved pain is often the most difficult aspect of management (Bornman & Beckingham, 2001). The physician, nurse, and dietitian emphasize to the patient and family the importance of avoiding alcohol and other foods that the patient has found tend to produce abdominal pain and discomfort. The fact that no other treatment is likely to relieve pain if the patient continues to consume alcohol is stressed to the patient. Diabetes mellitus resulting from dysfunction of the pancreatic islet cells is treated with diet, insulin, or oral antidiabetic agents.
1143
The hazard of severe hypoglycemia with alcohol use is stressed to the patient and family. Pancreatic enzyme replacement is indicated in the patient with malabsorption and steatorrhea (Trolli, Conwell & Zuccaro, 2001). SURGICAL MANAGEMENT Surgery is generally carried out to relieve abdominal pain and discomfort, restore drainage of pancreatic secretions, and reduce the frequency of acute attacks of pancreatitis. The surgery performed depends on the anatomic and functional abnormalities of the pancreas, including the location of disease within the pancreas, diabetes, exocrine insufficiency, biliary stenosis, and pseudocysts of the pancreas. Other factors taken into consideration in determining whether surgery is to be performed and what procedure is indicated include the patient’s continued use of alcohol and the likelihood that the patient will be able to manage the endocrine or exocrine changes that are expected after surgery. Pancreaticojejunostomy (also referred to as Roux-en-Y) with a side-to-side anastomosis or joining of the pancreatic duct to the jejunum allows drainage of the pancreatic secretions into the jejunum. Pain relief occurs by 6 months in more than 80% of the patients who undergo this procedure, but pain returns in a substantial number of patients as the disease itself progresses (Tierney et al., 2001). Other surgical procedures may be performed for different degrees and types of disease, ranging from revision of the sphincter of the ampulla of Vater, to internal drainage of a pancreatic cyst into the stomach (see Pancreatic Cyst discussion), to insertion of a stent, to wide resection or removal of the pancreas. A Whipple resection (pancreaticoduodenectomy) has been carried out to relieve the pain of chronic pancreatitis. Autotransplantation or implantation of the patient’s pancreatic islet cells has been attempted to preserve the endocrine function of the pancreas in patients who have undergone total pancreatectomy. Testing and refinement of this procedure continue in an effort to improve outcomes. When chronic pancreatitis develops as a result of gallbladder disease, the obstruction is treated by surgery to explore the common duct and remove the stones; usually, the gallbladder is removed at the same time. In addition, an attempt is made to improve the drainage of the common bile duct and the pancreatic duct by dividing the sphincter of Oddi, a muscle that is located at the ampulla of Vater (this surgical procedure is known as a sphincterotomy). A T-tube usually is placed in the common bile duct, requiring a drainage system to collect the bile postoperatively. Nursing care after such surgery is similar to that indicated after other biliary tract surgery. Patients who undergo surgery for chronic pancreatitis may experience weight gain and improved nutritional status; this may result from reduction in pain associated with eating rather than from correction of malabsorption. However, morbidity and mortality after these surgical procedures are high because of the poor physical condition of the patient before surgery and the concomitant occurrence of cirrhosis. Even after undergoing these surgical procedures, the patient is likely to continue to have pain and impaired digestion secondary to pancreatitis unless alcohol is avoided completely.
PANCREATIC CYSTS As a result of the local necrosis that occurs at the time of acute pancreatitis, collections of fluid may form in the vicinity of the pancreas. These become walled off by fibrous tissue and are called
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Unit 8
METABOLIC AND ENDOCRINE FUNCTION
pancreatic pseudocysts. They are the most common type of pancreatic cysts. Less common cysts occur as a result of congenital anomalies or are secondary to chronic pancreatitis or trauma to the pancreas. Diagnosis of pancreatic cysts and pseudocysts is made by ultrasound, computed tomography, and ERCP. ERCP may be used to define the anatomy of the pancreas and evaluate the patency of pancreatic drainage. Pancreatic pseudocysts may be of considerable size. Because of their location behind the posterior peritoneum, when they enlarge they impinge on and displace the stomach or the colon, which are adjacent. Eventually, through pressure or secondary infection, they produce symptoms and require drainage. Drainage into the gastrointestinal tract or through the skin and abdominal wall may be established. In the latter instance, the drainage is likely to be profuse and destructive to tissue because of the enzyme contents. Hence, steps must be taken to protect the skin near the drainage site from excoriation. Ointments protect the skin if they are applied before excoriation takes place. Another method involves the constant aspiration of digestive secretions from the drainage tract by means of a suction apparatus, so that skin contact with the digestive enzymes is avoided. This method requires expert nursing attention to ensure that the suction tube does not become dislodged and suction is not interrupted. Consultation with an enterostomal therapist is indicated to identify appropriate strategies to maintain drainage and protect the skin.
CANCER OF THE PANCREAS The incidence of pancreatic cancer has decreased slightly over the past 25 years in non-Caucasian men. It is the fifth leading cause of cancer deaths in the United States and occurs most frequently in the fifth to seventh decades of life (American Cancer Society, 2002). Cigarette smoking, exposure to industrial chemicals or toxins in the environment, and a diet high in fat, meat, or both are associated with pancreatic cancer, although their role is not completely clear. The risk for pancreatic cancer increases as the extent of cigarette smoking increases. Diabetes mellitus, chronic pancreatitis, and hereditary pancreatitis are also associated with pancreatic cancer. The pancreas can also be the site of metastasis from other tumors. Cancer may arise in any portion of the pancreas (in the head, the body, or the tail); clinical manifestations vary depending on the location of the lesion and whether functioning, insulinsecreting pancreatic islet cells are involved. Approximately 75% of pancreatic cancers originate in the head of the pancreas and give rise to a distinctive clinical picture. Functioning islet cell tumors, whether benign (adenoma) or malignant (carcinoma), are responsible for the syndrome of hyperinsulinism. With these exceptions, the symptoms are nonspecific, and patients usually do not seek medical attention until late in the disease; 80% to 85% of patients have advanced, unresectable tumor when first detected. In fact, pancreatic carcinoma has only a 2% to 5% survival rate at 5 years regardless of the stage of disease at diagnosis or treatment (Tierney et al., 2001).
Clinical Manifestations Pain, jaundice, or both are present in more than 90% of patients and, along with weight loss, are considered classic signs of pancreatic carcinoma. However, they often do not appear until the disease is far advanced. Other signs include rapid, profound, and
progressive weight loss as well as vague upper or midabdominal pain or discomfort that is unrelated to any gastrointestinal function and is often difficult to describe. Such discomfort radiates as a boring pain in the midback and is unrelated to posture or activity. It is often progressive and severe, requiring the use of opioids. It is often more severe at night. Relief may be obtained by sitting up and leaning forward, or accentuated when lying supine. Malignant cells from pancreatic cancer are often shed into the peritoneal cavity, increasing the likelihood of metastasis. The formation of ascites is common. An important sign, when present, is the onset of symptoms of insulin deficiency: glucosuria, hyperglycemia, and abnormal glucose tolerance. Thus, diabetes may be an early sign of carcinoma of the pancreas. Meals often aggravate epigastric pain, which usually occurs before the appearance of jaundice and pruritus.
Assessment and Diagnostic Findings Magnetic resonance imaging and computed tomography are used to identify the presence of pancreatic tumors. ERCP is also used in the diagnosis of pancreatic carcinoma. Cells obtained during ERCP are sent to the laboratory for examination. Gastrointestinal x-ray findings may demonstrate deformities in adjacent viscera caused by the impinging pancreatic mass. Percutaneous fine-needle aspiration biopsy of the pancreas is used to diagnose pancreatic tumors and confirm the diagnosis in patients whose tumors are not resectable, eliminating the stress and postoperative pain of ineffective surgery. In this procedure, a needle is inserted through the anterior abdominal wall into the pancreatic mass, guided by computed tomography, ultrasound, ERCP, or other imaging techniques. The aspirated material is examined for malignant cells. Although percutaneous biopsy is a valuable diagnostic tool, it has some potential drawbacks: a falsenegative result if small tumors are missed and seeding of cancer cells along the needle track. Low-dose radiation to the site may be used before the biopsy to reduce the risk of seeding. Percutaneous transhepatic cholangiography is another procedure that may be performed to identify obstructions of the biliary tract by a pancreatic tumor. Several tumor markers (eg, CA 19-9, CEA, DU-PAN-2) may be used in the diagnostic workup, but they are nonspecific for pancreatic carcinoma. These tumor markers are useful as indicators of disease progression. Angiography, computed tomography, and laparoscopy may be performed to determine whether the tumor can be removed surgically. Intraoperative ultrasonography has been used to determine if there is metastatic disease to other organs.
Medical Management If the tumor is resectable and localized (typically tumors in the head of the pancreas), the surgical procedure to remove it is usually extensive (see Medical Management in Tumors of the Head of the Pancreas). However, definitive surgical treatment (ie, total excision of the lesion) is often not possible because of the extensive growth when the tumor is finally diagnosed and because of the probable widespread metastases (especially to the liver, lungs, and bones). More often, treatment is limited to palliative measures. Although pancreatic tumors may be resistant to standard radiation therapy, the patient may be treated with radiation and chemotherapy (fluorouracil and gemcitabine). If the patient undergoes surgery, intraoperative radiation therapy (IORT) may be used to deliver a high dose of radiation to the tumor with minimal injury to other tissues. IORT may also be helpful in relief of
Chapter 40
Assessment and Management of Patients With Biliary Disorders
pain. Interstitial implantation of radioactive sources has also been used, although the rate of complications is high. A large biliary stent inserted percutaneously or by endoscopy may be used to relieve jaundice.
Nursing Management Pain management and attention to nutritional requirements are important nursing measures to improve the level of comfort. Skin care and nursing measures are directed toward relief of pain and discomfort associated with jaundice, anorexia, and profound weight loss. Specialty mattresses are beneficial and protect bony prominences from pressure. Pain associated with pancreatic cancer may be severe and may require liberal use of opioids; patientcontrolled analgesia should be considered for the patient with severe, escalating pain. Because of the poor prognosis and likelihood of short survival, end-of-life preferences are discussed and honored. If appropriate, the nurse refers the patient to hospice care. (See Chaps. 16 and 17, respectively, for discussion of care of the patient with cancer and end-of-life care.) PROMOTING HOME AND COMMUNITY-BASED CARE Teaching Patients Self-Care. The specific patient and family teaching indicated varies with the stage of disease and the treatment choices made by the patient. If the patient elects to receive chemotherapy, the nurse focuses teaching on prevention of side effects and complications of the agents used. If surgery is performed to relieve obstruction and establish biliary drainage, teaching addresses management of the drainage system and monitoring for complications. The nurse instructs the family about changes in the patient’s status that should be reported to the physician. Continuing Care. A referral for home care is indicated to help the patient and family deal with the physical problems and discomforts associated with pancreatic cancer and the psychological impact of the disease. The home care nurse assesses the patient’s physical status, fluid and nutritional status, and skin integrity and the adequacy of pain management. The nurse teaches the patient and family strategies to prevent skin breakdown and relieve pain, pruritus, and anorexia. It is important to discuss and arrange palliative care (hospice services) in an effort to relieve patient discomfort, assist with care, and comply with the patient’s end-of-life decisions and wishes.
TUMORS OF THE HEAD OF THE PANCREAS Sixty to eighty percent of pancreatic tumors occur in the head of the pancreas. Tumors in this region of the pancreas obstruct the common bile duct where the duct passes through the head of the pancreas to join the pancreatic duct and empty at the ampulla of Vater into the duodenum. The tumors producing the obstruction may arise from the pancreas, the common bile duct, or the ampulla of Vater.
Clinical Manifestations The obstructed flow of bile produces jaundice, clay-colored stools, and dark urine. Malabsorption of nutrients and fat-soluble vitamins may result from obstruction by the tumor to entry of bile in the gastrointestinal tract. Abdominal discomfort or pain
1145
and pruritus may be noted, along with anorexia, weight loss, and malaise. If these signs and symptoms are present, cancer of the head of the pancreas is suspected. The jaundice of this disease must be differentiated from that due to a biliary obstruction caused by a gallstone in the common duct, which is usually intermittent and appears typically in obese patients, most often women, who have had previous symptoms of gallbladder disease.
Assessment and Diagnostic Findings Diagnostic studies may include duodenography, angiography by hepatic or celiac artery catheterization, pancreatic scanning, percutaneous transhepatic cholangiography, ERCP, and percutaneous needle biopsy of the pancreas. Results of a biopsy of the pancreas may aid in the diagnosis.
Medical Management Before extensive surgery can be performed, a fairly long period of preparation is often necessary because the patient’s nutritional and physical condition is often quite compromised. Various liver and pancreatic function studies are performed. A diet high in protein along with pancreatic enzymes is often prescribed. Preoperative preparation includes adequate hydration, correction of prothrombin deficiency with vitamin K, and treatment of anemia to minimize postoperative complications. Parenteral nutrition and blood component therapy are frequently required. A biliary-enteric shunt may be performed to relieve the jaundice and, perhaps, to provide time for a thorough diagnostic evaluation. Total pancreatectomy (removal of the pancreas) may be performed if there is no evidence of direct extension of the tumor to adjacent tissues or regional lymph nodes. A pancreaticoduodenectomy (Whipple’s procedure or resection) is used for potentially resectable cancer of the head of the pancreas (Fig. 40-7). This procedure involves removal of the gallbladder, distal portion of the stomach, duodenum, head of the pancreas, and common bile duct and anastomosis of the remaining pancreas and stomach to the jejunum (Stanford, 2001). The result is removal of the tumor, allowing flow of bile into the jejunum. When the tumor cannot be excised, the jaundice may be relieved by diverting the bile flow into the jejunum by anastomosing the jejunum to the gallbladder, a procedure known as cholecystojejunostomy. The postoperative management of patients who have undergone a pancreatectomy or a pancreaticoduodenectomy is similar to the management of patients after extensive gastrointestinal and biliary surgery. The patient’s physical status is often less than optimal, increasing the risk for postoperative complications. Hemorrhage, vascular collapse, and hepatorenal failure remain the major complications of these extensive surgical procedures. The mortality rate after these procedures has improved because of advances in nutritional support and improved surgical techniques. A nasogastric tube and suction and parenteral nutrition allow the gastrointestinal tract to rest while promoting adequate nutrition.
Nursing Management Preoperatively and postoperatively, nursing care is directed toward promoting patient comfort, preventing complications, and assisting the patient to return to and maintain as normal and comfortable a life as possible. The nurse closely monitors the patient in the intensive care unit after surgery; the patient will have
1146
Unit 8
METABOLIC AND ENDOCRINE FUNCTION Common duct Cystic duct Gallbladder
Stomach
Duodenum
Pancreas
Common duct Cystic duct
Pancreas
Duodenum Stomach
multiple intravenous and arterial lines in place for fluid and blood replacement as well as for monitoring arterial pressures, and is on a mechanical ventilator in the immediate postoperative period. It is important to give careful attention to changes in vital signs, arterial blood gases and pressures, pulse oximetry, laboratory values, and urine output. The nurse must also consider the patient’s compromised nutritional status and risk for bleeding. Depending on the type of surgical procedure performed, malabsorption syndrome and diabetes mellitus are likely; the nurse must address these issues during acute and long-term patient care. Although the patient’s physiologic status is the focus of the health care team in the immediate postoperative period, the patient’s psychological and emotional state must be considered, along with that of the family. The patient has undergone major and risky surgery and is critically ill; thus, anxiety and depression may affect recovery. The immediate and long-term outcome of this extensive surgical resection is uncertain, and the patient and family require emotional support and understanding in the critical and stressful preoperative and postoperative periods. PROMOTING HOME AND COMMUNITY-BASED CARE Teaching Patients Self-Care. The patient who has undergone this extensive surgery requires careful and thorough preparation for self-care at home. The nurse instructs the patient and family about the need for modifications in the diet because of malabsorption and hyperglycemia resulting from the surgery. It is important to instruct them about the continuing need for pancreatic enzyme replacement, a low-fat diet, and vitamin supplementation.
FIGURE 40-7 Pancreatoduodenectomy (Whipple’s procedure or resection). End result of the resection of the carcinoma of the head of the pancreas or the ampulla of Vater. The common duct is sutured to the end of the jejunum, and the remaining portion of the pancreas and the end of the stomach are sutured to the side of the jejunum.
The nurse teaches the patient and family strategies to relieve pain and discomfort, along with strategies to manage drains, if present, and to care for the surgical incision. The patient and family members may require instruction about use of patientcontrolled analgesia, parenteral nutrition, wound care, skin care, and management of drainage. It is important to describe, verbally and in writing, the signs and symptoms of complications, and to teach the patient and family about indicators of complications that should be reported promptly. Discharge of the patient to a long-term care setting may be warranted after surgery as extensive as pancreatectomy or pancreaticoduodenectomy, particularly if the patient’s preoperative status was not optimal. Efforts are made to communicate to the long-term care staff about the teaching that has been provided so that instructions can be clarified and reinforced. During the recovery or long-term phase of care, the patient and family receive further instructions about care that they will carry out at home. Continuing Care. A referral for home care may be indicated when the patient returns home. The home care nurse assesses the patient’s physical and psychological status and the ability of the patient and family to manage needed care. The home care nurse provides needed physical care and monitors the adequacy of pain management. In addition, it is important to assess the patient’s nutritional status and monitor the use of parenteral nutrition. The nurse discusses the use of hospice services with the patient and family and makes a referral if indicated.
Chapter 40
Assessment and Management of Patients With Biliary Disorders
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PANCREATIC ISLET TUMORS
ULCEROGENIC TUMORS
The pancreas contains the islets (islands) of Langerhans, small nests of cells that secrete directly into the bloodstream and therefore are part of the endocrine system. The hormone insulin is essential for the metabolism of glucose. Diabetes mellitus (see Chap. 41) is the result of deficient secretion of insulin. At least two types of tumors of the pancreatic islet cells are known: those that secrete insulin (insulinoma) and those in which insulin secretion is not increased (“nonfunctioning” islet cell cancer). Insulinomas produce hypersecretion of insulin and cause an excessive rate of glucose metabolism. The resulting hypoglycemia may produce symptoms of weakness, mental confusion, and seizures. These symptoms may be relieved almost immediately by oral or intravenous administration of glucose. The 5-hour glucose tolerance test is helpful in diagnosing insulinoma and in distinguishing it from other causes of hypoglycemia.
Some tumors of the islets of Langerhans are associated with hypersecretion of gastric acid that produces ulcers in the stomach, duodenum, and jejunum. The result is referred to as ZollingerEllison syndrome. The hypersecretion is so great that even after partial gastric resection, enough acid is produced to cause further ulceration. When a marked tendency to develop gastric and duodenal ulcers is noted, an ulcerogenic tumor of the islets of Langerhans is considered. These tumors, which may be benign or malignant, are treated, when possible, by excision. Frequently, however, because of extension beyond the pancreas, removal is not possible. In many patients, a total gastrectomy may be necessary to reduce the secretion of gastric acid sufficiently to prevent further ulceration.
Surgical Management When a tumor of the islet cells has been diagnosed, surgical treatment with removal of the tumor usually is recommended. The tumors may be benign adenomas or they may be malignant. Complete removal usually results in almost immediate relief of symptoms. In some patients, symptoms may be produced by simple hypertrophy of this tissue rather than a tumor of the islet cells. In such cases, a partial pancreatectomy (removal of the tail and part of the body of the pancreas) is performed.
Nursing Management In preparing the patient for surgery, the nurse must be alert for symptoms of hypoglycemia and be ready to administer glucose as prescribed if symptoms occur. Postoperatively, the nursing management is the same as that after other upper abdominal surgical procedures, with special emphasis on monitoring serum glucose levels. Patient teaching is determined by the extent of surgery and the alterations in pancreatic function that result.
HYPERINSULINISM Hyperinsulinism results from overproduction of insulin by the pancreatic islets. Symptoms resemble those of excessive doses of insulin and are attributable to the same mechanism, an abnormal reduction in blood glucose levels. Clinically, it is characterized by episodes during which the patient experiences unusual hunger, nervousness, sweating, headache, and faintness; in severe cases, seizures and episodes of unconsciousness may occur. The findings at the time of surgery or at autopsy may indicate hyperplasia (overgrowth) of the islets of Langerhans or a benign or malignant tumor involving the islets and capable of producing large amounts of insulin (see preceding discussion). Occasionally, tumors of nonpancreatic origin produce an insulin-like material that can cause severe hypoglycemia that may be responsible for seizures coinciding with blood glucose levels too low to sustain normal brain function (ie, below 30 mg/dL [1.6 mmol/L]). All the symptoms that accompany spontaneous hypoglycemia are relieved by the oral or parenteral administration of glucose. Surgical removal of the hyperplastic or neoplastic tissue from the pancreas is the only successful method of treatment. About 15% of patients with spontaneous or functional hypoglycemia eventually develop diabetes mellitus.
REFERENCES AND SELECTED READINGS Books American Cancer Society. (2002). Cancer facts and figures. Atlanta: American Cancer Society. Blumgart, L. H., & Fong, Y. (Eds). (2000). Surgery of the liver and biliary tract (3rd ed.). London: W. B. Saunders Co. Ltd.
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Critical Thinking Exercises
1.
A 48-year-old woman is scheduled for a laparoscopic cholecystectomy. What postoperative care is indicated for this patient? What factors would you consider in preparing her for discharge? How would your care differ if she lived alone? How would you modify teaching for her if she understood little English?
2.
A 73-year-old man presents to the emergency department with an oral temperature of 100.6° F, nausea, vomiting of bile, and abdominal distention. He reports mild upper abdominal pain but is not a good historian due to a new onset of mild confusion and lethargy. His sclerae are slightly icteric, blood pressure is 88/50, and heart rate 116 per minute and regular. His primary physician reports fluctuating mild abnormalities in liver function studies over the past 6 months. Considering gerontologic changes in the hepatobiliary system, what diagnostic tests and medical and nursing interventions do you anticipate?
3.
A 57-year-old man has a history of alcoholism and cirrhosis. He is admitted to your unit with a diagnosis of acute pancreatitis. He is complaining of severe epigastric pain, vomiting, and diarrhea. What medications and laboratory tests would you expect to see prescribed for this patient? What physical assessment findings will you see? Describe nursing care for this patient, and compare and contrast care with and without the diagnosis of cirrhosis.
4.
A 69-year-old woman is being discharged to home with a diagnosis of advanced cancer of the pancreas. She has had a biliary drain inserted to relieve obstruction. What teaching about management of the drainage system is needed for the patient and her family? How would you modify your discharge plans for her if she lives alone and has no family support available?
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Braunwald, E., Fauci, A. S., Kasper, D. L., et al. (Eds.). (2001). Harrison’s principles of internal medicine (15th ed.). New York: McGrawHill. Dudek, S. (2001) Nutrition essentials for nursing practice. Philadelphia: Lippincott Williams & Wilkins. Evans, S. R. T., & Ascher, S. M. (Eds.) (1998). Hepatobiliary and pancreatic surgery. New York: Wiley-Liss. Feldman, M., Friedman, L. S., & Sleisenger, M. H. (Eds.). (2002). Sleisenger & Fordtran’s gastrointestinal and liver disease: pathophysiology, diagnosis, and management. Philadelphia: W. B. Saunders. Grenvik, A., Ayres, S. M., Holbrook, P. R., & Shoemaker, W. C. (Eds.). (2000). Textbook of critical care (4th ed.). Philadelphia: W. B. Saunders. Kacsoh, B. (2000). Endocrine physiology. New York: McGraw-Hill. Porth, C. M. (2002). Pathophysiology: Concepts of altered health states (6th ed.). Philadelphia: Lippincott Williams & Wilkins. Rakel, R. E., & Bope, E. T. (Eds.). (2001). Conn’s current therapy. Philadelphia: W. B. Saunders. Schiff, E. R., Sorrell, M. F., & Maddrey, W. C. (1999). Schiff’s diseases of the liver (8th ed.). Philadelphia: Lippincott-Raven. Schwartz, S. I. (Ed.) (1999). Principles of surgery (7th ed.). New York: McGraw-Hill. Tierney, L. M., McPhee, S. J., & Papadakis, M. A. (Eds.). (2001). Current medical diagnosis and treatment. New York: Lange Medical Books/McGraw-Hill. Van Leeuwen, D. J., Reeders, W. A. J., & Ariyama, J. (Eds.). (2000). Imaging in hepatobiliary and pancreatic disease. London: W. B. Saunders Co. Ltd. Wolfe, M. M. (2000). Therapy of digestive disorders. Philadelphia: W. B. Saunders. Wu, G. Y., & Israel, J. (Eds.). (1998). Diseases of the liver and bile ducts. Totowa, NJ: Humana Press.
Journals Asterisks indicate nursing research articles. General Barish, M. A., Yucel, E. K., & Ferrucci, J. T. (1999). Magnetic resonance cholangiopancreatography. New England Journal of Medicine, 341(4), 258–264. Kalloo, A. N., & Kantsevoy, S. V. (2001). Gallstones and biliary diseases. Primary Care Clinics in Office Practice, 28(3), 591–606. Gallbladder Disease Ahmed, A., Cheung, R. C., & Keefe, E. B. (2000). Management of gallstones and their complications. American Family Physician, 61(6), 1673–1688. Borzellino, G., deManzoni, G., & Ricci, F., et al. (1999). Emergency cholecystostomy and subsequent cholecystectomy for acute gallstone cholecystitis in the elderly. British Journal of Surgery, 86(12), 1521–1525. Bowser, L., & Schutz, S. M. (2000). The role of surveillance ERCP in preventing episodic cholangitis in patients with recurrent bile duct stones. Gastrointestinal Endoscopy, 51(2), 118–121. De Groen, P. C., Gores, G. J., LaRusso, N. F., et al. (1999). Biliary tract cancers. New England Journal of Medicine, 341(18), 1368–1378. Donovan, J. M. (1999). Physical and metabolic factors in gallstone pathogenesis. Gastroenterology Clinics of North America, 28(1), 75–97. Farrar, J. A. (2001). Acute cholecystitis. American Journal of Nursing, 101(1), 35–36. Kowdley, K. V. (2000). Ursodeoxycholic acid therapy in hepatobiliary disease. American Journal of Medicine, 108(6), 481–486. Lai, P. B. S., Kwong, K. H., & Leung, K. L., et al. (1998). Randomized trial of early versus delayed laparoscopic cholecystectomy for acute cholecystitis. British Journal of Surgery, 85(6), 764–767.
Lauter, D. M., & Froines, E. J. (2000). Laparoscopic common duct exploration in the management of choledocholithiasis. American Journal of Surgery, 179(5), 372–374. Lee, L., & Yee, J. (2000). Diagnostic dilemma. American Journal of Medicine, 108(6), 503, 511. Memon, M., Hassaballa, H., & Memon, M. (2000). Laparoscopic common bile duct exploration: The past, the present, and the future. American Journal of Surgery, 179(4), 309–315. Shaffer, E. A. (2000). Morphine and biliary pain revisited. Gut, 46(6), 750–751. Siddiqui, M. N. (1999). Laparoscopic management of complicated gallstone disease. British Journal of Surgery, 86(11), 1481–1482. Strasberg, S. M. (1999). Laparoscopic biliary surgery. Gastroenterology Clinics of North America, 28(1), 117–132. Pancreatic Disorders Aronson, B. S. (1999). Update on acute pancreatitis. MedSurg Nursing, 8(1), 9–16. Berger, H. G., & Isenmann, R. (1999). Surgical management of necrotizing pancreatitis. Surgical Clinics of North America, 79(4), 783–799. Bornman, P. C., & Beckingham, I. J. (2001). ABC of diseases of liver, pancreas, and biliary system. Chronic pancreatitis. British Medical Journal, 322(7287), 660–663. Clain, J. E., & Pearson, R. K. (1999). Diagnosis of chronic pancreatitis. Surgical Clinics of North America, 79(4), 829–843. Dejong, C. H., Greve, J. W. & Soeters, P. B. (2001). Nutrition in patients with acute pancreatitis. Current Opinion in Critical Care, 7(4), 251–256. Hale, A. S., Moseley, M. J., & Warner, S. C. (2000). Treating pancreatitis in the acute care setting. Dimensions of Critical Care Nursing, 19(4), 16–21. Johnson, F. M. G. (2001). Alterations in taste sensation: A case presentation of a patient with end-stage pancreatic cancer. Cancer Nursing, 24(2), 149–155. Lankish, P. G. (1999). Progression from acute to chronic pancreatitis: A physician’s view. Surgical Clinics of North America, 79(4), 815–824. Munoz, A., & Katerndahl, D. A. (2000). Diagnosis and management of acute pancreatitis. American Family Physician, 62(1), 164–174, 39–42, 244. Pennachio, D. L. (2002). The latest approaches to pancreatic disease. Patient Care for the Nurse Practitioner, 4(9), 41–44, 47–48. Quillen, S. M. (2001). Identification of pancreatitis in the ambulatory setting. Gastroenterology Nursing, 24(1), 20–22. Sakorafas, G. H., Farnell, M. B., Nagorney, D. M., & Sarr, M. G. (2001). Surgical management of chronic pancreatitis at the Mayo Clinic. Surgical Clinics of North America, 81(2), 457–465. Schlapman, N. (2001). Spotting acute pancreatitis. RN, 64(11), 55–58. Stanford, P. (2001). Surgical approaches to pancreatic cancer. Nursing Clinics of North America, 36(3), 567–577. *Trolli, P. A., Conwell, D. L., & Zuccaro, G. Jr. (2001). Pancreatic enzyme therapy and nutritional status of outpatients with chronic pancreatitis. Gastroenterology Nursing, 24(2), 84–87.
RESOURCES AND WEBSITES American Gastroenterological Association, 7910 Woodmont Avenue, Suite 700, Bethesda, MD 20814; (301) 654-2055; http://www.gastro.org. National Digestive Diseases Information Clearing House, 2 Information Way, Bethesda, MD 20892-3570; (301) 654-3810; http://www. niddk.nih.gov. National Endocrine Society, 4350 East West Highway, Suite 500, Bethesda, MD 20814; (301) 941-0200; http://www.endo-society.org. National Pancreas Foundation, P.O. Box 15333, Boston, MA 02215; http://www.pancreasfoundation.org.
Chapter
41 ●
Assessment and Management of Patients With Diabetes Mellitus
LEARNING OBJECTIVES
●
On completion of this chapter, the learner will be able to: 1. Differentiate between type 1 and type 2 diabetes. 2. Describe etiologic factors associated with diabetes. 3. Relate the clinical manifestations of diabetes to the associated 4. 5. 6. 7. 8. 9. 10. 11. 12. 13.
pathophysiologic alterations. Identify the diagnostic and clinical significance of blood glucose tests. Explain the dietary modifications used for management of people with diabetes. Describe the relationship between diet, exercise, and medication (ie, insulin or oral hypoglycemic agents) for people with diabetes. Develop a plan for teaching insulin self-administration. Identify the role of oral antidiabetic agents in diabetic therapy. Differentiate between hypoglycemia and diabetic ketoacidosis, and hyperosmolar nonketotic syndrome. Describe management strategies for a person with diabetes to use during “sick days.” Describe the major macrovascular, microvascular, and neuropathic complications of diabetes and the self-care behaviors important in their prevention. Identify the teaching aids and community support groups available for people with diabetes. Use the nursing process as a framework for care of the patient with diabetes.
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D
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METABOLIC AND ENDOCRINE FUNCTION
iabetes mellitus is a group of metabolic diseases characterized by elevated levels of glucose in the blood (hyperglycemia) resulting from defects in insulin secretion, insulin action, or both (American Diabetes Association [ADA], Expert Committee on the Diagnosis and Classification of Diabetes Mellitus, 2003). Normally a certain amount of glucose circulates in the blood. The major sources of this glucose are absorption of ingested food in the gastrointestinal (GI) tract and formation of glucose by the liver from food substances. Insulin, a hormone produced by the pancreas, controls the level of glucose in the blood by regulating the production and storage of glucose. In the diabetic state, the cells may stop responding to insulin or the pancreas may stop producing insulin entirely. This leads to hyperglycemia, which may result in acute metabolic complications such as diabetic ketoacidosis (DKA) and hyperglycemic hyperosmolar nonketotic syndrome (HHNS). Long-term effects of hyperglycemia contribute to macrovascular complications (coronary artery disease, cerebrovascular disease, and peripheral vascular disease), chronic microvascular complications (kidney and eye disease), and neuropathic complications (diseases of the nerves). Diabetes mellitus affects about 17 million people, 5.9 million of whom are undiagnosed. In the United States, approximately 800,000 new cases of diabetes are diagnosed yearly (Mokdad et al.,
2000). Diabetes is especially prevalent in the elderly, with up to 50% of people older than 65 suffering some degree of glucose intolerance. Among adults in the United States, diagnosed cases of diabetes increased 49% from 1990 to 2000, and similar increases are expected to continue (Centers for Disease Control and Prevention [CDC], 2002). Minority groups share a disproportionate burden of diabetes compared to non-minority groups. African-Americans and other racial and ethnic groups (Native Americans and persons of Hispanic origin) are more likely than Caucasians to develop diabetes and are at greater risk for many of the complications and higher death rates due to diabetes than Caucasians (U.S. Public Health Service [USPHS], 2000; CDC, 2002). Chart 41-1 summarizes other risk factors for diabetes mellitus. The far-reaching and devastating physical, social, and economic consequences of diabetes are as follows:
• In the United States, diabetes is the leading cause of non•
traumatic amputations, blindness among working-age adults, and end-stage renal disease (USPHS, 2000). Diabetes is the third leading cause of death by disease, primarily because of the high rate of cardiovascular disease (myocardial infarction, stroke, and peripheral vascular disease) among people with diabetes.
Glossary alpha glucosidase inhibitor: a category of oral agents used to treat type 2 diabetes that delay the absorption of carbohydrate, resulting in lower postprandial blood glucose levels continuous subcutaneous insulin infusion: a small device that delivers insulin on a 24-hour basis as basal insulin; it is also programmed by the patient to deliver a bolus dose before eating a meal in an attempt to mimic normal pancreatic function diabetes mellitus: a group of metabolic diseases characterized by hyperglycemia resulting from defects in insulin secretion, insulin action, or both diabetic ketoacidosis (DKA): a metabolic derangement in type 1 diabetes that results from a deficiency of insulin. Highly acidic ketone bodies are formed, resulting in acidosis; usually requires hospitalization for treatment and is usually caused by nonadherence to the insulin regimen, concurrent illness, or infection. fasting plasma glucose (FPG): blood glucose determination obtained in the laboratory after fasting for more than 8 hours. Although plasma levels are specified in diagnostic criteria, blood glucose levels, which are slightly higher than plasma levels, are more commonly used. glycosylated hemoglobin (hemoglobin A1C): a long-term measure of glucose control that is a result of glucose attaching to hemoglobin for the life of the red blood cell (120 days). The goal of diabetes therapy is a normal to near-normal level of glycosy-
lated hemoglobin (referred to as HgbA1C or A1C), the same as in the nondiabetic population. hyperglycemia: elevated blood glucose level—fasting level greater than 110 mg/dL (6.1 mmol/L); 2-hour postprandial level greater than 140 mg/dL (7.8 mmol/L) hyperglycemic hyperosmolar nonketotic syndrome (HHNS): a metabolic disorder of type 2 diabetes resulting from a relative insulin deficiency initiated by an intercurrent illness that raises the demand for insulin; associated with polyuria and severe dehydration hypoglycemia: low blood glucose level (less than 60 mg/dL [less than 2.7 mmol/L]) insulin: a hormone secreted by the beta cells of the islets of Langerhans of the pancreas that is necessary for the metabolism of carbohydrates, proteins, and fats; a deficiency of insulin results in diabetes mellitus impaired fasting glucose (IFG), impaired glucose tolerance (IGT): a metabolic stage intermediate between normal glucose homeostasis and diabetes; not clinical entities in their own right but risk factors for future diabetes and cardiovascular disease islet cell transplant: an investigational procedure in which purified islet cells from cadaver donors are injected into the portal vein of the liver, with the goal of having these cells secrete insulin and cure type 1 diabetes. ketone: a highly acidic substance formed when the liver breaks down free fatty acids in the absence of insulin. The result is diabetic ketoacidosis.
nephropathy: a long-term complication of diabetes in which the kidney cells are damaged; characterized by microalbuminuria in early stages and progressing to endstage renal disease neuropathy: a long-term complication of diabetes resulting from damage to the nerve cell. retinopathy: a long-term complication of diabetes in which the microvascular system of the eye is damaged self-monitoring of blood glucose (SMBG): a method of capillary blood glucose testing in which the patient pricks his/her finger and applies a drop of blood to a test strip that is read by a meter sulfonylurea: a classification of oral antidiabetic medication for treating type 2 diabetes; enhances insulin secretion and insulin action thiazolidinedione: a class of oral antidiabetic medications that reduce insulin resistance in target tissues, enhancing insulin action without directly stimulating insulin secretion type 1 diabetes: a metabolic disorder characterized by an absence of insulin production and secretion from autoimmune destruction of the beta cells of the islets of Langerhans in the pancreas. Formerly called insulin-dependent, juvenile or type I diabetes. type 2 diabetes: a metabolic disorder characterized by the relative deficiency of insulin production and a decreased insulin action and increased insulin resistance. Formerly called non-insulin-dependent, adult-onset, or type II diabetes.
Chapter 41
Assessment and Management of Patients With Diabetes Mellitus
Chart 41-1
Risk Factors for Diabetes Mellitus Family history of diabetes (ie, parents or siblings with diabetes) Obesity (ie, ≥20% over desired body weight or BMI ≥27 kg/m2) Race/ethnicity (eg, African Americans, Hispanic Americans, Native Americans, Asian Americans, Pacific Islanders) Age ≥45 years Previously identified impaired fasting glucose or impaired glucose tolerance Hypertension (≥140/90 mm Hg) HDL cholesterol level ≤35 mg/dL (0.90 mmol/L) and/or triglyceride level ≥250 mg/dL (2.8 mmol/L) History of gestational diabetes or delivery of babies over 9 lbs Used with permission of American Diabetes Association. (1998). Report of the Expert Committee on the Diagnosis and Classification of Diabetes Mellitus. Diabetes Care, 21 (Suppl 1), S5–S19.
• Hospitalization rates for people with diabetes are 2.4 times
greater for adults and 5.3 times greater for children than for the general population.
The economic cost of diabetes continues to rise because of increasing health care costs and an aging population. Half of all people who have diabetes and who are older than 65 are hospitalized each year, and severe and life-threatening complications often contribute to the increased rates of hospitalization. Costs related to diabetes are estimated to be almost $100 billion annually, including direct medical care expenses and indirect costs attributable to disability and premature death (CDC, 2002). The primary goals of treatment for patients with diabetes include controlling blood glucose levels and preventing acute and long-term complications. Thus, the nurse who cares for diabetic patients must assist them to develop self-care management skills.
Classification of Diabetes There are several different types of diabetes mellitus; they may differ in cause, clinical course, and treatment. The major classifications of diabetes are:
• Type 1 diabetes (previously referred to as insulin-dependent diabetes mellitus)
• Type 2 diabetes (previously referred to as non-insulindependent diabetes mellitus)
• Gestational diabetes mellitus (ADA, Expert Committee on •
the Diagnosis and Classification of Diabetes Mellitus, 2003) Diabetes mellitus associated with other conditions or syndromes
OVERVIEW The terms “insulin-dependent diabetes” and “non-insulindependent diabetes” and their acronyms (IDDM and NIDDM, respectively) are no longer used because they have resulted in classification of patients on the basis of the treatment of their diabetes rather than the underlying etiology. Use of Roman numerals (type I and type II) to distinguish between the two types has been changed to type 1 and type 2 to reduce confusion (ADA, Expert Committee on the Diagnosis and Classification of Diabetes Mellitus, 2003).
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Approximately 5% to 10% of people with diabetes have type 1 diabetes, in which the insulin-producing pancreatic beta cells are destroyed by an autoimmune process. As a result, they produce little or no insulin and require insulin injections to control their blood glucose levels. Type 1 diabetes is characterized by an acute onset, usually before age 30 (CDC, Diabetes Surveillance, 1999). Approximately 90% to 95% of people with diabetes have type 2 diabetes (CDC, Data Factsheet, 2002), which results from decreased sensitivity to insulin (called insulin resistance) and impaired beta cell functioning resulting in decreased insulin production (Quinn, 2001a). Type 2 diabetes is first treated with diet and exercise. If elevated glucose levels persist, diet and exercise are supplemented with oral hypoglycemic agents. In some individuals with type 2 diabetes, oral agents do not control hyperglycemia, and insulin injections are required. In addition, some individuals whose type 2 diabetes can usually be controlled with diet, exercise, and oral agents may require insulin injections during periods of acute physiologic stress (eg, illness or surgery). Type 2 diabetes occurs more among people who are older than 30 years and obese (Diabetes Information Clearing House, 2001). Diabetes complications may develop in any person with type 1 or type 2 diabetes, not only in patients who take insulin. Some patients with type 2 diabetes who are treated with oral medications may have the impression that they do not really have diabetes or that they simply have “borderline” diabetes. They may believe that, compared with diabetic patients who require insulin injections, their diabetes is not a serious problem. It is important for the nurse to emphasize to these individuals that they do have diabetes and not a borderline problem with sugar (glucose). Borderline diabetes is classified as impaired glucose tolerance (IGT) or impaired fasting glucose (IFG) and refers to a condition in which blood glucose levels fall between normal levels and levels considered diagnostic for diabetes. Table 41-1 summarizes the major classifications of diabetes, current terminology, old labels, and major clinical characteristics. This classification system is dynamic in two ways. First, research findings suggest many differences among individuals within each category. Second, except for those with type 1 diabetes, patients may move from one category to another. For example, a woman with gestational diabetes may, after delivery, move into the type 2 category. These types also differ in their etiology, clinical course, and management.
PHYSIOLOGY AND PATHOPHYSIOLOGY OF DIABETES Insulin is secreted by beta cells, which are one of four types of cells in the islets of Langerhans in the pancreas. Insulin is an anabolic, or storage, hormone. When a person eats a meal, insulin secretion increases and moves glucose from the blood into muscle, liver, and fat cells. In those cells, insulin:
• Transports and metabolizes glucose for energy • Stimulates storage of glucose in the liver and muscle (in the form of glycogen)
• Signals the liver to stop the release of glucose • Enhances storage of dietary fat in adipose tissue • Accelerates transport of amino acids (derived from dietary protein) into cells
Insulin also inhibits the breakdown of stored glucose, protein, and fat. During fasting periods (between meals and overnight), the pancreas continuously releases a small amount of insulin (basal
Table 41-1
• Classification of Diabetes Mellitus and Related Glucose Intolerances
CURRENT CLASSIFICATION
PREVIOUS CLASSIFICATIONS
CLINICAL CHARACTERISTICS AND CLINICAL IMPLICATIONS
Type 1 (5%–10% of all diabetes)
Juvenile diabetes Juvenile-onset diabetes Ketosis-prone diabetes Brittle diabetes Insulin-dependent diabetes mellitus (IDDM)
Type 2 (90%–95% of all diabetes: obese— 80% of type 2; nonobese—20% of type 2)
Adult-onset diabetes Maturity-onset diabetes Ketosis-resistant diabetes Stable diabetes Non–insulin-dependent diabetes (NIDDM)
Onset any age, but usually young ( 10 mm Hg b. Extreme hypotension c. Weak or absent peripheral pulses d. Altered level of consciousness e. Bulging neck veins 3. Prepare patient for cardiac ultrasound to aid in diagnosis of pericardial effusion and cardiac tamponade. 4. If cardiac tamponade develops, prepare patient for emergency pericardiocentesis.
1. About 30%–50% of chronic renal failure patients develop pericarditis due to uremia; fever, chest pain, and a pericardial friction rub are classic signs. 2. Pericardial effusion is a common fatal sequela of pericarditis. Signs of an effusion include a paradoxical pulse (> 10 mm Hg drop in blood pressure during inspiration) and signs of shock due to compression of the heart by a large effusion. Cardiac tamponade exists when the patient is severely compromised hemodynamically. 3. Cardiac ultrasound is useful in visualizing pericardial effusions and cardiac tamponade. 4. Cardiac tamponade is a life-threatening condition, with a high mortality rate. Immediate aspiration of fluid from the pericardial space is essential.
• Has strong and equal peripheral pulses • Absence of a paradoxical pulse • Absence of pericardial effusion or tamponade on cardiac ultrasound
• Patient has normal heart sounds
Hypertension 1. Monitor and record blood pressure as indicated. 2. Administer antihypertensive medications as prescribed. 3. Encourage compliance with dietary and fluid restriction therapy. 4. Teach patient to report signs of fluid overload, vision changes, headaches, edema, or seizures.
1. Provides objective data for monitoring. Elevated levels may indicate nonadherence to the treatment regimen. 2. Antihypertensive medications play a key role in treatment of hypertension associated with chronic renal failure. 3. Adherence to diet and fluid restrictions and dialysis schedule prevents excess fluid and sodium accumulation. 4. These are indications of inadequate control of hypertension and need to alter therapy.
• Blood pressure within normal limits • Reports no headaches, visual problems, or seizures
• Edema is absent • Demonstrates compliance with dietary and fluid restrictions
Anemia 1. Monitor RBC count, hemoglobin, and hematocrit levels as indicated. 2. Administer medications as prescribed, including iron and folic acid supplements, Epogen, and multivitamins. 3. Avoid drawing unnecessary blood specimens. 4. Teach patient to prevent bleeding: avoid vigorous nose blowing and contact sports, and use a soft toothbrush. 5. Administer blood component therapy as indicated.
1. Provides assessment of degree of anemia. 2. RBCs need iron, folic acid, and vitamins to be produced. Epogen stimulates the bone marrow to produce RBC. 3. Anemia is worsened by drawing numerous specimens. 4. Bleeding from anywhere in the body worsens anemia.
• Patient has a normal color without pallor • Exhibits hematology values within acceptable limits
• Experiences no bleeding from any site
5. Blood component therapy may be needed if the patient has symptoms.
Bone Disease and Metastatic Calcifications 1. Administer the following medications as prescribed: phosphate binders, calcium supplements, vitamin D supplements. 2. Monitor serum lab values as indicated (calcium, phosphorus, aluminum levels) and report abnormal findings to physician. 3. Assist patient with an exercise program.
1. Chronic renal failure causes numerous physiologic changes affecting calcium, phosphorus, and vitamin D metabolism. 2. Hyperphosphatemia, hypocalcemia, and excess aluminum accumulation are common in chronic renal failure. 3. Bone demineralization increases with immobility.
• Exhibits serum calcium, phosphorus, and
aluminum levels within acceptable ranges
• Exhibits no symptoms of hypocalcemia • Has no bone demineralization on bone scan • Discusses importance of maintaining activity level and exercise program
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Unit 9
RENAL AND URINARY TRACT FUNCTION
medications. This is because of the frequent use of multipleprescription and over-the-counter medications by elderly patients. The incidence of systemic diseases, such as atherosclerosis, hypertension, heart failure, diabetes, and cancer, increases with advancing age, predisposing older adults to renal disease associated with these disorders. Therefore, nurses in all settings need to be alert for signs and symptoms of renal dysfunction in elderly patients. With age, the kidney is less able to respond to acute fluid and electrolyte changes. Therefore, acute problems need to be prevented if possible or recognized and treated quickly to avoid kidney damage. When the elderly patient must undergo extensive diagnostic tests, or when new medications (eg, diuretic agents) are added, precautions must be taken to prevent dehydration, which can compromise marginal renal function and lead to ARF. The elderly patient may develop atypical and nonspecific signs and symptoms of disturbed renal function and fluid and electrolyte imbalances. Recognition of these problems is further hampered by their association with preexisting disorders and the misconception that they are normal changes of aging. ACUTE RENAL FAILURE IN OLDER ADULTS The incidence of ARF is increasing in older, hospitalized patients. About half of patients who develop ARF during hospitalization for a medical or surgical problem are older than 60 years of age. Evidence also demonstrates that ARF is often seen in the community setting. Nurses in the ambulatory setting need to be cognizant of the risk for ARF in their elderly patients, especially those undergoing diagnostic testing or procedures that can result in dehydration. The mortality rate is slightly higher for ARF in elderly patients than for their younger counterparts. The etiology of ARF in older adults includes prerenal causes, such as dehydration, and intrarenal causes, such as nephrotoxic agents (medications, contrast agents). Diabetes mellitus increases the risk for contrast agent-induced renal failure because of preexisting renal insufficiency and the imposed fluid restriction needed for many tests. Suppression of thirst, enforced bed rest, lack of drinking water, and confusion all contribute to the older patient’s failure to consume adequate fluids and may lead to dehydration and compromise of already decreased renal function. CHRONIC RENAL FAILURE IN OLDER ADULTS Historically, the age of patients developing ESRD steadily rose each year, but it appears to have stabilized since 1993 at a mean age of 60 years. In the past, rapidly progressive glomerulonephritis, membranous glomerulonephritis, and nephrosclerosis were the most common causes of chronic renal failure in the elderly. Today, however, diabetes mellitus and hypertension are the leading causes of chronic renal failure in the elderly (Bakris et al., 2000). Other common causes of chronic renal failure in the elderly population are interstitial nephritis and urinary tract obstruction. The signs and symptoms of renal disease in the elderly are commonly nonspecific. The occurrence of symptoms of other disorders (heart failure, dementia) can mask the symptoms of renal disease and delay or prevent diagnosis and treatment. The patient often develops signs and symptoms of nephrotic syndrome, such as edema and proteinuria. Hemodialysis and peritoneal dialysis have been used effectively in treating elderly patients (Carey et al., 2001). Although there is no specific age limitation for renal transplantation, concomitant disorders (ie, coronary artery disease, peripheral vascular disease) have made it a less common treatment for the elderly.
The outcome, however, is comparable to that of younger patients. Some elderly patients elect not to participate in these treatment strategies. Conservative management, including nutritional therapy, fluid control, and medications, such as phosphate binders, may be considered in patients who are not suitable for or elect not to participate in dialysis or transplantation.
Kidney Transplantation Kidney transplantation has become the treatment of choice for most patients with ESRD. During the past 40 years, more than 380,000 kidney transplantations have been performed worldwide, and more than 174,000 have been performed in the United States. This number includes over 10,000 kidney-pancreas transplantations. In January 2003 there were almost 54,000 persons on the waiting list for kidney transplantation (http://www.unos.org., December 25, 2002). Patients choose kidney transplantation for various reasons, such as the desire to avoid dialysis or to improve their sense of well-being and the wish to lead a more normal life. Additionally, the cost of maintaining a successful transplantation is one-third the cost of treating a dialysis patient. Kidney transplantation involves transplanting a kidney from a living donor or human cadaver to a recipient who has ESRD (Chart 45-9). Kidney transplants from well-matched living donors who are related to the patient (those with compatible ABO and HLA antigens) are slightly more successful than those from cadaver donors. The success rate increases if kidney transplantation from a living donor is performed before dialysis is initiated (Mange, Joffe & Feldman, 2001). Due to the overwhelming numbers of persons on kidney transplant waiting lists, new techniques for matching nonrelated living donors are being developed (Gridelli & Remuzzi, 2000). A nephrectomy of the patient’s own native kidneys may be performed before transplantation. The transplanted kidney is placed in the patient’s iliac fossa anterior to the iliac crest. The ureter of the newly transplanted kidney is transplanted into the bladder or anastomosed to the ureter of the recipient (Fig. 45-5).
Chart 45-9
Organ Donation
An inadequate number of available kidneys remains the greatest limitation to treating patients with end-stage renal disease successfully. For those interested in donating a kidney, the National Kidney Foundation provides written information describing the organ donation program and a card specifying the organs to be donated in the event of death. The organ donation card is signed by the donor and two witnesses and should be carried by the donor at all times. Procurement of an adequate number of kidneys for potential recipients is still a major problem, despite national legislation that requires relatives of deceased patients or patients declared brain-dead to be asked if they would consider organ donation. In some states in the United States, drivers can indicate their desire to be organ donors on their driver’s license application or renewal.
Chapter 45
Management of Patients With Urinary Disorders
Inferior vena cava
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Abdominal aorta Adrenal gland
1. Diseased kidney removed. Adrenal gland remains intact. Renal artery and vein tied off.
2. Transplanted donor kidney cradled in ilium.
FIGURE 45-5
Renal transplantation: (1) The diseased kidney may be removed and the renal artery and vein tied off. (2) The transplanted kidney is placed in the iliac fossa. (3) The renal artery of the donated kidney is sutured to the iliac artery, and the renal vein is sutured to the iliac vein. (4) The ureter of the donated kidney is sutured to the bladder or to the patient’s ureter.
3. Renal artery sutured to iliac artery. Renal vein sutured to iliac vein.
Ureter
IIium
Internal iliac artery Inguinal ligament
4. Ureter sutured.
PREOPERATIVE MANAGEMENT
Nursing Management
Preoperative management goals include bringing the patient’s metabolic state to a level as close to normal as possible, making sure that the patient is free of infection, and preparing the patient for surgery and the postoperative course.
The nursing aspects of preoperative care are similar to those for patients undergoing other elective abdominal surgery. Preoperative teaching can be conducted in a variety of settings, including the outpatient preadmission area, the hospital, or the transplantation clinic during the preliminary workup phase. Patient teaching addresses postoperative pulmonary hygiene, pain management options, dietary restrictions, intravenous and arterial lines, tubes (indwelling catheter and possibly a nasogastric tube), and early ambulation. The patient who receives a kidney from a living related donor may be concerned about the donor and how the donor will tolerate the surgical procedure. Most patients have been on dialysis for months or years before transplantation. Many have waited months to years for a kidney transplant and are anxious about the surgery, possible rejection, and the need to return to dialysis. Helping the patient to deal with these concerns is part of the nurse’s role in preoperative management, as is teaching the patient about what to expect after surgery.
Medical Management A complete physical examination is performed to detect and treat any conditions that could cause complications after transplantation. Tissue typing, blood typing, and antibody screening are performed to determine compatibility of the tissues and cells of the donor and recipient. Other diagnostic tests must be completed to identify conditions requiring treatment before transplantation. The lower urinary tract is studied to assess bladder neck function and to detect ureteral reflux. The patient must be free of infection at the time of renal transplantation because after surgery the patient will receive medications to prevent transplant rejection. These medications suppress the immune response, leaving the patient immunosuppressed and at risk for infection. Therefore, the patient is evaluated and treated for any infections, including gingival (gum) disease and dental caries. A psychosocial evaluation is conducted to assess the patient’s ability to adjust to the transplant, coping styles, social history, social support available, and financial resources. A history of psychiatric illness is important to ascertain because psychiatric conditions are often aggravated by the corticosteroids needed for immunosuppression after transplantation. Hemodialysis is often performed the day before the scheduled transplantation procedure to optimize the patient’s physical status if a dialysis routine had already been established. However, it is preferable to avoid initiation of dialysis before transplantation when a donor kidney is available (Mange et al., 2001).
POSTOPERATIVE MANAGEMENT The goal of care is to maintain homeostasis until the transplanted kidney is functioning well. The patient whose kidney functions immediately has a more favorable prognosis than the patient whose kidney does not.
Immunosuppressive Therapy The survival of a transplanted kidney depends on the ability to block the body’s immune response to the transplanted kidney. To overcome or minimize the body’s defense mechanism, immunosuppressant agents such as azathioprine (Imuran), corticosteroids (prednisone), cyclosporine, and OKT-3 (a monoclonal antibody) are administered (Shapiro, 2000b).
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Cyclosporine is available in a microemulsion form (Neoral), which delivers the medication reliably, thus producing a steady-state serum concentration. Tacrolimus (Prograf, formerly called FK506) is similar to cyclosporine and about 100 times more potent. Mycophenolate (CellCept, RS-61433) has been approved by the U.S. Food and Drug Administration (FDA) solely for the prevention of renal transplant rejection. It may be used in patients who have failed to respond to the standard corticosteroid pulse therapy or OKT-3. Antilymphocyte globulin is occasionally used to modify the immune response. Leukapheresis, lymph drainage, and cyclophosphamide (Cytoxan) are other methods of immunosuppression, but they are rarely used. Treatment with combinations of these new agents has dramatically improved survival rates. The newest class of agents, the first of which is sirolimus, is called target of rapamycin (TOR) inhibitors; these agents are used with cyclosporine for maintenance therapy. Immunosuppressive drug therapy after kidney transplantation continues to evolve (Chan, Gaston & Hariharan, 2001). Doses of immunosuppressant agents are gradually reduced (tapered) over a period of several weeks, depending on the patient’s immunologic response to the transplant. The patient will, however, take some form of antirejection medication for the entire time that he or she has the transplanted kidney (Chart 45-10). The clinical profile of neurotoxicity caused by immunosuppression has changed. When toxic levels are reached, both cyclosporine and tacrolimus may produce a clinical spectrum that varies from tremor and acute confusional state to status epilepticus and major speech or language abnormalities. Coma has become an unusual manifestation (Baan et al., 2001; Shapiro, 2000; Wijdicks, 2001).
Chart 45-10
Renal Transplant Rejection and Infection
Renal graft rejection and failure may occur within 24 hours (hyperacute), within 3 to 14 days (acute), or after many years (chronic). It is not uncommon for rejection to occur during the first year after transplantation. Detecting Rejection Ultrasonography may be used to detect enlargement of the kidney; percutaneous renal biopsy (most reliable) and x-ray techniques are used to evaluate transplant rejection. If the body rejects the transplanted kidney, the patient needs to return to dialysis. The rejected kidney may or may not be removed, depending on when the rejection occurs (acute versus chronic) and the risk for infection if the kidney is left in place. Potential Infection About 75% of kidney transplant recipients have at least one episode of infection in the first year after transplantation because of immunosuppressant therapy. Immunosuppressants of the past made the transplant recipient more vulnerable to opportunistic infections (candidiasis, cytomegalovirus, Pneumocystis carinii pneumonia) and infection with other relatively nonpathogenic viruses, fungi, and protozoa, which can be a major hazard. Cyclosporine therapy has reduced the incidence of opportunistic infections because it selectively exerts its effect, sparing T cells that protect the patient from life-threatening infections. In addition, combination immunosuppressant therapy and improved clinical care have produced 1-year patient survival rates approaching 100% and graft survival exceeding 90%. Infections, however, remain a major cause of death at all points in time for kidney transplant recipients (Chan, Gaston & Hariharan, 2001).
Postoperative Nursing Management ASSESSING THE PATIENT FOR TRANSPLANT REJECTION After kidney transplantation, the nurse assesses the patient for signs and symptoms of transplant rejection: oliguria, edema, fever, increasing blood pressure, weight gain, and swelling or tenderness over the transplanted kidney or graft. Patients receiving cyclosporine may not exhibit the usual signs and symptoms of acute rejection. In these patients, the only sign may be an asymptomatic rise in the serum creatinine level (more than a 20% rise is considered acute rejection). The results of blood chemistry tests (BUN and creatinine) and leukocyte and platelet counts are monitored closely because immunosuppression depresses the formation of leukocytes and platelets. The patient is closely monitored for infection because of susceptibility to impaired healing and infection related to immunosuppressive therapy and complications of renal failure.
!
NURSING ALERT A distinction must be made between infection and rejection because impaired renal function and fever are evidence of both infection and rejection, and their treatments differ.
Clinical manifestations of infection include shaking chills, fever, rapid heartbeat and respirations (tachycardia and tachypnea), and either an increase or a decrease in WBCs (leukocytosis or leukopenia). PREVENTING INFECTION Infection may be introduced through the urinary tract, the respiratory tract, the surgical site, or other sources. Urine cultures are performed frequently because of the high incidence of bacteriuria during early and late stages of transplantation. Any type of wound drainage should be viewed as a potential source of infection because drainage is an excellent culture medium for bacteria. Catheter and drain tips may be cultured when removed by cutting off the tip of the catheter or drain (using aseptic technique) and placing the cut portion in a sterile container to be taken to the laboratory for culture. The nurse ensures that the patient is protected from exposure to infection by hospital staff, visitors, and other patients with active infections. Careful hand hygiene is imperative; facemasks may be worn by hospital staff and visitors to reduce the risk for transmitting infectious agents while the patient is receiving high doses of immunosuppressants. MONITORING URINARY FUNCTION The vascular access for hemodialysis is monitored to ensure patency and to evaluate for evidence of infection. After successful renal transplantation, the vascular access device may clot, possibly from improved coagulation with the return of renal function. Hemodialysis may be necessary postoperatively to maintain homeostasis until the transplanted kidney is functioning well. A kidney from a living donor related to the patient usually begins to function immediately after surgery and may produce large quantities of dilute urine. A kidney from a cadaver donor may undergo acute tubular necrosis and therefore may not function for 2 or 3 weeks, during which time anuria, oliguria, or polyuria may be present. During this stage, the patient may experience significant changes in fluid and electrolyte status. Therefore, careful monitoring is indicated. The output from the urinary catheter (connected to a closed drainage system) is measured every hour. Intravenous fluids are administered on the basis of urine volume and serum electrolyte levels and as prescribed by the physician.
Chapter 45 Hemodialysis may be required if fluid overload and hyperkalemia occur (Gridelli & Remuzzi, 2000). ADDRESSING PSYCHOLOGICAL CONCERNS The rejection of a transplanted kidney remains a matter of great concern to the patient, the family, and the health care team for many months. The fears of kidney rejection and the complications of immunosuppressive therapy (Cushing’s syndrome, diabetes, capillary fragility, osteoporosis, glaucoma, cataracts, acne) place tremendous psychological stresses on the patient. Anxiety and uncertainty about the future and difficult posttransplantation adjustment are often sources of stress for the patient and family. An important nursing function is the assessment of the patient’s stress and coping. The nurse uses each visit with the patient to determine if the patient and family are coping effectively and the patient is complying with the prescribed medication regimen. If indicated or requested, the nurse refers the patient for counseling. MONITORING AND MANAGING POTENTIAL COMPLICATIONS The patient undergoing kidney transplantation is at risk for the postoperative complications that are associated with any surgical procedure. In addition, the patient’s physical condition may be compromised because of the complications associated with longstanding renal failure and its treatment. Therefore, careful assessment for the complications related to renal failure and those associated with a major surgical procedure are important aspects of nursing care. Strategies to promote surgical recovery (breathing exercises, early ambulation, care of the surgical incision) are important aspects of postoperative care. GI ulceration and corticosteroid-induced bleeding may occur. Fungal colonization of the GI tract (especially the mouth) and urinary bladder may occur secondary to corticosteroid and antibiotic therapy. Closely monitoring the patient and notifying the physician about the occurrence of these complications are important nursing interventions. In addition, the patient is monitored closely for signs and symptoms of adrenal insufficiency if the treatment has included use of corticosteroids.
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transplantation, due in part to the increasing age of transplantation patients. An additional problem is possible malignancy; patients receiving long-term immunosuppressive therapy have been found to develop cancers more frequently than the general population. Because of the usual need for health promotion along with the increased risks for malignancy because of immunosuppressive therapy, the patient is reminded of the importance of health promotion and health screening. The American Association of Kidney Patients (listed at the end of this chapter) is a nonprofit organization that serves the needs of those with kidney disease. It has many helpful suggestions for patients and family members learning to cope with dialysis and transplantation.
Urolithiasis Urolithiasis refers to stones (calculi) in the urinary tract. Stones are formed in the urinary tract when urinary concentrations of substances such as calcium oxalate, calcium phosphate, and uric acid increase. This is referred to as supersaturation and is dependent on the amount of the substance, ionic strength, and pH of the urine.
Pathophysiology Stones can also form when there is a deficiency of substances that normally prevent crystallization in the urine, such as citrate, magnesium, nephrocalcin, and uropontin. The fluid volume status of the patient (stones tend to occur more often in dehydrated patients) is another factor playing a key role in stone development. Calculi may be found anywhere from the kidney to the bladder. They vary in size from minute granular deposits, called sand or gravel, to bladder stones as large as an orange. The different sites of calculi formation in the urinary tract are shown in Figure 45-6.
PROMOTING HOME AND COMMUNITY-BASED CARE Teaching Patients Self-Care. The nurse works closely with the patient and family to be sure that they understand the need for continuing the immunosuppressive therapy as prescribed. Additionally, the patient and family are instructed to assess for and report signs and symptoms of transplant rejection, infection, or significant adverse effects of the immunosuppressant regimen. These include decreased urine output; weight gain; malaise; fever; respiratory distress; tenderness over the transplanted kidney; anxiety; depression; changes in eating, drinking, or other habits; and changes in blood pressure readings. The patient is instructed to inform other health care providers (eg, dentist) about the kidney transplant and the use of immunosuppressive agents. Continuing Care. The patient needs to know that follow-up care after transplantation is a lifelong necessity. Individual verbal and written instructions are provided concerning diet, medication, fluids, daily weight, daily measurement of urine, management of intake and output, prevention of infection, resumption of activity, and avoidance of contact sports in which the transplanted kidney may be injured. Because of the risk of other potential complications, the patient is followed closely. Cardiovascular disease is now the major cause of morbidity and mortality after
FIGURE 45-6 (urolithiasis).
Various sites of calculi formation in the urinary tract
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Certain factors favor the formation of stones, including infection, urinary stasis, and periods of immobility (slows renal drainage and alters calcium metabolism). In addition, increased calcium concentrations in blood and urine promote precipitation of calcium and formation of stones (about 75% of all renal stones are calcium-based). Causes of hypercalcemia (high serum calcium) and hypercalciuria (high urine calcium) include the following:
• • • • • • •
Hyperparathyroidism Renal tubular acidosis Cancers Granulomatous diseases (sarcoidosis, tuberculosis), which may cause increased vitamin D production by the granulomatous tissue Excessive intake of vitamin D Excessive intake of milk and alkali Myeloproliferative diseases (leukemia, polycythemia vera, multiple myeloma), which produce an unusual proliferation of blood cells from the bone marrow
For patients with stones containing uric acid, struvite, or cystine, a thorough physical examination and metabolic workup are indicated because of associated disturbances contributing to the stone formation. Uric acid stones (5% to 10% of all stones) may be seen in patients with gout or myeloproliferative disorders. Struvite stones account for 15% of urinary calculi and form in persistently alkaline, ammonia-rich urine caused by the presence of ureasesplitting bacteria such as Proteus, Pseudomonas, Klebsiella, Staphylococcus, or Mycoplasma species. Predisposing factors for struvite stones (commonly called infection stones) include neurogenic bladder, foreign bodies, and recurrent UTIs. Cystine stones (1% to 2% of all stones) occur exclusively in patients with a rare inherited defect in renal absorption of cystine (an amino acid). Urinary stone formation may also occur with inflammatory bowel disease and in patients with an ileostomy or bowel resection because these patients absorb more oxalate. Some medications that are known to cause stones in some patients include antacids, acetazolamide (Diamox), vitamin D, laxatives, and high doses of aspirin. In many patients, however, no cause may be found. Urinary stones account for about 328,000 hospital admissions each year. The occurrence of urinary stones occurs predominantly in the third to fifth decades of life and affects men more than women. About half of patients with a single renal stone have another episode within 5 years. Most stones contain calcium or magnesium in combination with phosphorus or oxalate. Most stones are radiopaque and can be detected by x-ray studies (Bihl & Meyers, 2001).
Clinical Manifestations Signs and symptoms of stones in the urinary tract depend on obstruction, infection, and edema. When the stones block the flow of urine, obstruction develops, producing an increase in hydrostatic pressure and distending the renal pelvis and proximal ureter. Infection (pyelonephritis and cystitis with chills, fever, and dysuria) can occur from constant irritation by the stone. Some stones cause few, if any, symptoms while slowly destroying the functional units (nephrons) of the kidney; others cause excruciating pain and discomfort. Stones in the renal pelvis may be associated with an intense, deep ache in the costovertebral region. Hematuria is often present; pyuria may also be noted. Pain originating in the renal area radi-
ates anteriorly and downward toward the bladder in the female and toward the testis in the male. If the pain suddenly becomes acute, with tenderness over the costovertebral area, and nausea and vomiting appear, the patient is having an episode of renal colic. Diarrhea and abdominal discomfort may occur. These GI symptoms are due to renointestinal reflexes and the anatomic proximity of the kidneys to the stomach, pancreas, and large intestine. Stones lodged in the ureter (ureteral obstruction) cause acute, excruciating, colicky, wavelike pain, radiating down the thigh and to the genitalia. Often, the patient has a desire to void, but little urine is passed, and it usually contains blood because of the abrasive action of the stone. This group of symptoms is called ureteral colic. Colic is mediated by prostaglandin E, a substance that increases ureteral contractility and renal blood flow and that leads to increased intraureteral pressure and pain. In general, the patient spontaneously passes stones 0.5 to 1 cm in diameter. Stones larger than 1 cm in diameter usually must be removed or fragmented (broken up by lithotripsy) so that they can be removed or passed spontaneously. Stones lodged in the bladder usually produce symptoms of irritation and may be associated with UTI and hematuria. If the stone obstructs the bladder neck, urinary retention occurs. If infection is associated with a stone, the condition is far more serious, with sepsis threatening the patient’s life.
Assessment and Diagnostic Findings The diagnosis is confirmed by x-ray films of the kidneys, ureter, and bladder (KUB) or by ultrasonography, intravenous urography, or retrograde pyelography. Blood chemistries and a 24-hour urine test for measurement of calcium, uric acid, creatinine, sodium, pH, and total volume are part of the diagnostic workup. Dietary and medication histories and family history of renal stones are obtained to identify factors predisposing the patient to the formation of stones. When stones are recovered (stones may be freely passed by the patient or removed through special procedures), chemical analysis is carried out to determine their composition. Stone analysis can provide a clear indication of the underlying disorder. For example, calcium oxalate or calcium phosphate stones usually indicate disorders of oxalate or calcium metabolism, whereas urate stones suggest a disturbance in uric acid metabolism.
Medical Management The basic goals of management are to eradicate the stone, to determine the stone type, to prevent nephron destruction, to control infection, and to relieve any obstruction that may be present. The immediate objective of treatment of renal or ureteral colic is to relieve the pain until its cause can be eliminated. Opioid analgesics are administered to prevent shock and syncope that may result from the excruciating pain. NSAIDs may be as effective as other analgesics in treating renal stone pain. They provide specific pain relief because they inhibit the synthesis of prostaglandin E. Hot baths or moist heat to the flank areas may also be useful. Unless the patient is vomiting or has heart failure or any other condition requiring fluid restriction, fluids are encouraged. This increases the hydrostatic pressure behind the stone, assisting it in its downward passage. A high, around-the-clock fluid intake reduces the concentration of urinary crystalloids, dilutes the urine, and ensures a high urine output.
Chapter 45 Nutritional therapy plays an important role in preventing renal stones. Fluid intake is the mainstay of most medical therapy for renal stones. Unless contraindicated, any patient with renal stones should drink at least eight 8-ounce glasses of water daily to keep the urine dilute. A urine output exceeding 2 L a day is advisable (Chart 45-11). Calcium Stones. Historically, patients with calcium-based renal stones were advised to restrict calcium in their diet. Recent evidence, however, has questioned the advisability of this practice, except for patients with type II absorptive hypercalciuria (half of all patients with calcium stones), in whom stones are clearly due to excess dietary calcium. Current research supports a liberal fluid intake along with dietary restriction of protein and sodium. It is thought that a high-protein diet is associated with increased urinary excretion of calcium and uric acid, thereby causing a supersaturation of these substances in the urine. Similarly, a high sodium intake has been shown in some studies to increase the amount of calcium in the urine. The urine may be acidified by use of medications such as ammonium chloride or acetohydroxamic acid (Lithostat) (Trinchieri, Zanetti, Curro & Lizzano, 2001; Williams, Child, Hudson et al., 2001). Cellulose sodium phosphate (Calcibind) may be effective in preventing calcium stones. It binds calcium from food in the intestinal tract, reducing the amount of calcium absorbed into the circulation. If increased parathormone production (resulting in increased serum calcium levels in blood and urine) is a factor in the formation of stones, therapy with thiazide diuretics may be beneficial in reducing the calcium loss in the urine and lowering the elevated parathormone levels. Uric Acid Stones. For uric acid stones, the patient is placed on a low-purine diet to reduce the excretion of uric acid in the urine. Foods high in purine (shellfish, anchovies, asparagus, mushrooms, and organ meats) are avoided, and other proteins may be limited. Allopurinol (Zyloprim) may be prescribed to reduce serum uric acid levels and urinary uric acid excretion. The urine is alkalinized. For cystine stones, a low-protein diet is prescribed, the urine is alkalinized, and penicillamine is administered to reduce the amount of cystine in the urine. Oxalate Stones. For oxalate stones, a dilute urine is maintained and the intake of oxalate is limited. Many foods contain oxalate; however, only certain foods have been proved to increase the uri-
Chart 45-11
Dietary Recommendations for Prevention of Kidney Stones
• Restricting protein to 60 g/day is recommended to decrease urinary excretion of calcium and uric acid.
• A sodium restriction of 3–4 g/day is recommended. Table salt and high-sodium foods should be reduced because sodium competes with calcium for reabsorption in the kidneys. • Low-calcium diets are not generally recommended, except for true absorptive hypercalciuria. Evidence shows that limiting calcium, especially in women, can lead to osteoporosis and does not prevent renal stones. • Oxalate-containing foods (spinach, strawberries, rhubarb, tea, peanuts, wheat bran) may be restricted.
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nary excretion of oxalate significantly. These include spinach, strawberries, rhubarb, chocolate, tea, peanuts, and wheat bran. SURGICAL MANAGEMENT If the stone is not passed spontaneously or if complications occur, treatment modalities may include surgical, endoscopic, or other procedures—for example, ureteroscopy, extracorporeal shock wave lithotripsy (ESWL), or endourologic (percutaneous) stone removal. Ureteroscopy (Fig. 45-7) involves first visualizing the stone and then destroying it. Access to the stone is accomplished by inserting a ureteroscope into the ureter and then inserting a laser, electrohydraulic lithotriptor, or ultrasound device through the ureteroscope to fragment and remove the stones. A stent may be inserted and left in place for 48 hours or more after the procedure to keep the ureter patent. Hospital stays are generally brief, and some patients can be treated as outpatients. ESWL is a noninvasive procedure used to break up stones in the calyx of the kidney (see Fig. 45-7B). After the stones are fragmented to the size of grains of sand, the remnants of the stones are spontaneously voided. In ESWL, a high-energy amplitude of pressure, or shock wave, is generated by the abrupt release of energy and transmitted through water and soft tissues. When the shock wave encounters a substance of different intensity (a renal stone), a compression wave causes the surface of the stone to fragment. Repeated shock waves focused on the stone eventually reduce it to many small pieces. These small pieces are excreted in the urine, usually without difficulty. The need for anesthesia for the procedure depends on the type of lithotriptor used, which determines the number and intensity of shock waves delivered. An average treatment comprises between 1,000 and 3,000 shocks. The first-generation lithotriptors required use of either regional or general anesthesia. Second- and thirdgeneration lithotriptors, many of which also employ ultrasound guidance, require little to no anesthesia (Tombolini, Ruoppolo, Bellorofonte et al., 2000). Although the shock waves usually do not damage other tissue, discomfort from the multiple shocks may occur. The patient is observed for obstruction and infection resulting from blockage of the urinary tract by stone fragments. All urine is strained after the procedure; voided gravel or sand is sent to the laboratory for chemical analysis. Several treatments may be necessary to ensure disintegration of stones. Although lithotripsy is a costly treatment, the length of hospital stay is decreased, as is expense, because an invasive surgical procedure to remove the renal stone is avoided. Endourologic methods of stone removal (see Fig. 45-7C ) may be used to extract renal calculi that cannot be removed by other procedures. A percutaneous nephrostomy or a percutaneous nephrolithotomy (which are similar procedures) may be performed, and a nephroscope is introduced through the dilated percutaneous tract into the renal parenchyma. Depending on its size, the stone may be extracted with forceps or by a stone retrieval basket. Alternatively, an ultrasound probe may be introduced through the nephrostomy tube. Then, ultrasonic waves are used to pulverize the stone. Small stone fragments and stone dust are irrigated and suctioned out of the collecting system. Larger stones may be further reduced by ultrasonic disintegration and then removed with forceps or a stone retrieval basket (Streem, 2000). Electrohydraulic lithotripsy is a similar method in which an electrical discharge is used to create a hydraulic shock wave to break up the stone. A probe is passed through the cystoscope, and
Unit 9
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Optical lens Light source
Urethral opening
Bladder
Cystoscope
Tube that infuses irrigant
A Dual-imaging system Computer display
X-ray overhead Dual-imaging system
X-ray film cassette Shock wave generating system
B
Ultrasound system
Alligator forceps Kidney stone fragments
C
FIGURE 45-7
Methods of treating renal stones. (A) During a cystoscopy, which is used for removing small renal stones located close to the bladder, a ureteroscope is inserted into the ureter to visualize the stone. The stone is then fragmented or captured and removed. (B) Extracorporeal shock wave lithotripsy (ESWL) is used for most symptomatic nonpassable upper urinary tract stones. Electromagnetically generated shock waves are focused over the area of the renal stone. The high-energy dry shock waves pass through the skin and fragment the stone. (C) Percutaneous nephrolithotomy is used to treat larger stones. A percutaneous tract is formed and a nephroscope is inserted through it. Then the stone is extracted or pulverized.
Chapter 45 the tip of the lithotriptor is placed near the stone. The strength of the discharge and pulse frequency can be varied. This procedure is performed under topical anesthesia. After the stone is extracted, the percutaneous nephrostomy tube is left in place for a time to ensure that the ureter is not obstructed by edema or blood clots. The most common complications are hemorrhage, infection, and urinary extravasation. After the tube is removed, the nephrostomy tract closes spontaneously. Chemolysis, stone dissolution using infusions of chemical solutions (eg, alkylating agents, acidifying agents) for the purpose of dissolving the stone, is an alternative treatment sometimes used in patients who are at risk for complications of other types of therapy, who refuse to undergo other methods, or who have stones (struvite) that dissolve easily. A percutaneous nephrostomy is performed, and the warm irrigating solution is allowed to flow continuously onto the stone. The irrigating solution exits the renal collecting system by means of the ureter or the nephrostomy tube. The pressure inside the renal pelvis is monitored during the procedure. Several of these treatment modalities may be used in combination to ensure removal of the stones (Bihl & Meyers, 2001; Joshi, Kumar & Timoney, 2001; Liou & Streem, 2001). Surgical removal was the major mode of therapy before the advent of lithotripsy. Today, however, surgery is performed in only 1% to 2% of patients. Surgical intervention is indicated if the stone does not respond to other forms of treatment. It may also be performed to correct anatomic abnormalities within the kidney to improve urinary drainage. If the stone is in the kidney, the surgery performed may be a nephrolithotomy (incision into the kidney with removal of the stone) or a nephrectomy, if the kidney is nonfunctional secondary to infection or hydronephrosis. Stones in the kidney pelvis are removed by a pyelolithotomy, those in the ureter by ureterolithotomy, and those in the bladder by cystotomy. If the stone is in the bladder, an instrument may be inserted through the urethra into the bladder, and the stone is crushed in the jaws of this instrument. Such a procedure is called a cystolitholapaxy (Maheshwari, Oswal & Bansal, 1999; Monga & Oglevie, 2000; Streem, 2000). Nursing management following kidney surgery is discussed in Chapter 44.
NURSING PROCESS: THE PATIENT WITH KIDNEY STONES Assessment The patient with suspected renal stones is assessed for pain and discomfort as well as associated symptoms, such as nausea, vomiting, diarrhea, and abdominal distention. The severity and location of pain are determined, along with any radiation of the pain. Nursing assessment also includes observing for signs and symptoms of UTI (chills, fever, dysuria, frequency, and hesitancy) and obstruction (frequent urination of small amounts, oliguria, or anuria). The urine is inspected for blood and is strained for stones or gravel. The history focuses on factors that predispose the patient to urinary tract stones or that may have precipitated the current episode of renal or ureteral colic. Predisposing factors include family history of stones, the presence of cancer or bone marrow disorders or the use of chemotherapeutic agents, inflammatory bowel disease, or a diet high in calcium or purines. Factors that may precipitate stone formation in the patient predisposed to renal calculi include episodes of dehydration, prolonged immobilization, and infection. The patient’s knowledge about renal
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stones and measures to prevent their occurrence or recurrence is also assessed.
Diagnosis NURSING DIAGNOSES Based on the assessment data, the nursing diagnoses in the patient with renal stones may include the following: • Acute pain related to inflammation, obstruction, and abrasion of the urinary tract • Deficient knowledge regarding prevention of recurrence of renal stones COLLABORATIVE PROBLEMS/ POTENTIAL COMPLICATIONS Based on assessment data, potential complications that may develop include the following: • Infection and sepsis (from UTI and pyelonephritis) • Obstruction of the urinary tract by a stone or edema with subsequent acute renal failure
Planning and Goals The major goals for the patient may include relief of pain and discomfort, prevention of recurrence of renal stones, and absence of complications.
Nursing Interventions RELIEVING PAIN Immediate relief of the severe pain from renal or ureteral colic is accomplished with the administration of opioid analgesic agents (intravenous or intramuscular administration may be prescribed to provide rapid relief) or NSAIDs (ie, ketorolac). The patient is encouraged and assisted to assume a position of comfort. If activity brings some pain relief, the patient is assisted to ambulate. The pain level is monitored closely, and increases in severity are reported promptly to the physician so that relief can be provided and additional treatment initiated. The patient is prepared for other treatment (eg, lithotripsy, percutaneous stone removal, ureteroscopy, or surgery) if severe pain is unrelieved and the stone is not passed spontaneously. MONITORING AND MANAGING POTENTIAL COMPLICATIONS Because renal stones increase the risk for infection, sepsis, and obstruction of the urinary tract, the patient is instructed to report decreased urine volume and bloody or cloudy urine. The total urine output and patterns of voiding are monitored. Increased fluid intake is encouraged to prevent dehydration and increase hydrostatic pressure within the urinary tract to promote passage of the stone. If the patient cannot take adequate fluids orally, intravenous fluids are prescribed. Ambulation is encouraged as a means of moving the stone through the urinary tract. Patients with calculi require frequent nursing observation to detect the spontaneous passage of a stone. All urine is strained through gauze because uric acid stones may crumble. Any blood clots passed in the urine should be crushed and the sides of the urinal and bedpan inspected for clinging stones. The patient is instructed to report any sudden increases in pain immediately because of the possibility of a stone fragment obstructing a ureter. Analgesic medications are administered as prescribed for the relief of pain and discomfort.
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Vital signs, including temperature, are monitored closely to detect early signs of infection. UTIs may be associated with renal stones due to an obstruction from the stone or from the stone itself. All infections should be treated with the appropriate antibiotic agent before efforts are made to dissolve the stone (DeLeskey & Massi-Ventura, 2000). PROMOTING HOME AND COMMUNITY-BASED CARE Teaching Patients Self-Care Because the risk of recurring renal stones is high, the nurse provides education about the causes of kidney stones and ways to prevent their recurrence (Chart 45-12). The patient is encouraged to follow a regimen to avoid further stone formation. One facet of prevention is to maintain a high fluid intake because stones form more readily in concentrated urine. A patient who has shown a tendency to form stones should drink enough fluid to excrete greater than 2,000 mL of urine every 24 hours (preferably 3,000 to 4,000 mL), should adhere to the prescribed diet, and should avoid sudden increases in environmental temperatures, which may cause a fall in urinary volume. Occupations and activities that produce excessive sweating can lead to severe temporary dehydration; therefore, fluid intake should be increased. Sufficient fluids should be taken in the evening to prevent urine from becoming too concentrated at night. Urine cultures may be performed every 1 to 2 months the first year and periodically thereafter. Recurrent UTI is treated vigorously. Because prolonged immobilization slows renal drainage and alters calcium metabolism, increased mobility is encouraged whenever possible. In addition, excessive ingestion of vitamins (especially vitamin D) and minerals is discouraged. If lithotripsy, percutaneous stone removal, ureteroscopy, or other surgical procedures for stone removal have been performed, the patient is instructed about the signs and symptoms of complications that need to be reported to the physician. The importance of follow-up to assess kidney function and to ensure the eradication or removal of all kidney stones is emphasized to the patient and family. If the patient underwent ESWL, the nurse must provide instructions for home care and necessary follow-up. The patient is encouraged to increase fluid intake to assist in the passage of stone fragments, which may occur for 6 weeks to several months after the procedure. The patient and family are instructed about signs and symptoms that indicate complications, such as fever, decreas-
Chart 45-12
• PATIENT EDUCATION Avoiding Recurrent Kidney Stones • Follow prescribed diet closely. • During the day, drink fluids (ideally water) every 1 to 2 hours. • Drink two glasses of water at bedtime and an additional glass at each nighttime awakening to prevent urine from becoming too concentrated during the night. • Avoid activities that cause excessive sweating and dehydration. • Avoid sudden increases in environmental temperatures that may cause excessive sweating and dehydration. • Contact primary health care provider at the first sign of a urinary tract infection.
ing urine output, and pain. It is also important to tell the patient to expect hematuria (it is anticipated in all patients), but it should disappear within 4 to 5 days. If the patient has a stent in the ureter, hematuria may be expected until it is removed. The patient is instructed to notify the physician if nausea or vomiting, a temperature greater than 38°C (about 101°F), or pain unrelieved by the prescribed medication occurs. The patient is also informed that a bruise may be observed on the treated side of the back. Continuing Care The patient is monitored closely in follow-up care to ensure that treatment has been effective and that no complications, such as obstruction, infection, renal hematoma, or hypertension, have developed. During the patient’s visits to the clinic or physician’s office, the nurse has the opportunity to assess the patient’s understanding of ESWL and possible complications. Additionally, the nurse has the opportunity to assess the patient’s understanding of factors that increase the risk for recurrence of renal calculi and strategies to reduce those risks. The patient’s ability to monitor urinary pH and interpret the results is assessed during follow-up visits to the clinic or physician’s office. Because of the high risk for recurrence, the patient with renal stones needs to understand the signs and symptoms of stone formation, obstruction, and infection and the importance of reporting these signs promptly. If medications are prescribed for the prevention of stone formation, the actions and importance of the medications are explained to the patient.
Evaluation EXPECTED PATIENT OUTCOMES Expected patient outcomes may include: 1. Reports relief of pain 2. States increased knowledge of health-seeking behaviors to prevent recurrence a. Consumes increased fluid intake (at least eight 8-ounce glasses of fluid per day) b. Participates in appropriate activity c. Consumes diet prescribed to reduce dietary factors predisposing to stone formation d. Recognizes symptoms to be reported to health care provider (fever, chills, flank pain, hematuria) e. Monitors urinary pH as directed f. Takes prescribed medication as directed to reduce stone formation 3. Experiences no complications a. Reports no signs or symptoms of sepsis or infection b. Voids 200 to 400 mL per voiding of clear urine without evidence of bleeding c. Experiences absence of dysuria, frequency, and hesitancy d. Maintains normal body temperature
Genitourinary Trauma Various types of injuries of the flank, back, or upper abdomen may result in trauma to the kidney, ureter, bladder, or urethra. Trauma to the kidney accounts for about half of all cases of genitourinary trauma (Dreitlein, Suner & Basler, 2001).
Chapter 45 RENAL TRAUMA Normally, the kidneys are protected by the rib cage and musculature of the back posteriorly and by a cushion of abdominal wall and viscera anteriorly. They are highly mobile and are fixed only at the renal pedicle (stem of renal blood vessels and the ureter). With traumatic injury, the kidney can be thrust against the lower ribs, resulting in contusion and rupture. Rib fractures or fractures of the transverse process of the upper lumbar vertebrae may be associated with renal contusion or laceration. Injuries may be blunt (automobile and motorcycle crashes, falls, athletic injuries, assaults) or penetrating (gunshot wounds, stabbings). Failure to wear seat belts contributes to the incidence of renal trauma in motor vehicle crashes. Up to 80% of patients with renal trauma have associated injuries of other internal organs. Renal trauma may be classified by the mechanism of injury: blunt or penetrating. Blunt renal trauma accounts for 80% to 90% of all renal injuries; penetrating renal trauma accounts for the remaining 10% to 20% (Bayerstock, Simons & McLoughlin, 2001). Blunt renal trauma is classified into one of four groups, as follows:
• Contusion: bruises or hemorrhages under the renal capsule; capsule and collecting system intact
• Minor laceration: superficial disruption of the cortex; renal medulla and collecting system are not involved
• Major laceration: parenchymal disruption extending into cortex and medulla, possibly involving the collecting system
• Vascular injury: tears of renal artery or vein The most common renal injuries are contusions, lacerations, ruptures, and renal pedicle injuries or small internal lacerations of the kidney (Fig. 45-8). The kidneys receive half of the blood
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flow from the abdominal aorta; therefore, even a fairly small renal laceration can produce massive bleeding. About 70% of patients are in shock when admitted to the hospital (Dreitlein et al., 2001). Clinical manifestations include pain, renal colic (due to blood clots or fragments obstructing the collecting system), hematuria, mass or swelling in the flank, ecchymoses, and lacerations or wounds of the lateral abdomen and flank. Hematuria is the most common manifestation of renal trauma; its presence after trauma suggests renal injury. There is no relationship between the degree of hematuria and the degree of injury. Hematuria may not occur, or it may be detectable only on microscopic examination. Signs and symptoms of hypovolemia and shock are likely with significant hemorrhage.
URETERAL TRAUMA Penetrating trauma and unintentional injury during surgery are the major causes of trauma to the ureters. Gunshot wounds account for 95% of ureteral injuries, which may range from contusions to complete transection. Unintentional injury to the ureter may occur during gynecologic or urologic surgery (Mathevet, Valencia, Cousin et al., 2001; Perez-Brayfield, Keane, Krishnan et al., 2001). There are no specific signs or symptoms of ureteral injury; many traumatic injuries are discovered during exploratory surgery. If the ureteral trauma is not detected and urine leakage continues, fistulas are likely to develop. Intravenous urography detects 90% of ureteral injuries and can be performed on the operating table in patients undergoing emergent surgery. Surgical repair with placement of stents (to divert urine away from the anastomoses) is usually necessary.
BLADDER TRAUMA Injury to the bladder may occur with pelvic fractures and multiple trauma or from a blow to the lower abdomen when the bladder is full. Blunt trauma may result in contusion evident as an ecchymosis—a large, discolored bruise resulting from escape of blood into the tissues and involving a segment of the bladder wall— or in rupture of the bladder extraperitoneally, intraperitoneally, or both. Complications from these injuries include hemorrhage, shock, sepsis, and extravasation of blood into the tissues, which must be treated promptly (Morey, Iverson, Swan et al., 2001).
Expanding hematoma may cause rupture, extravasation, exsanguination
Contusion
URETHRAL TRAUMA Laceration
Pedicle injury; may cause ischemic necrosis of kidney
Bleeding into collecting system, shock
Medical Management
Blood in urine
FIGURE 45-8
Urethral injuries usually occur with blunt trauma to the lower abdomen or pelvic region. Many patients also have associated pelvic fractures. The classic triad of symptoms comprises blood at the urinary meatus, inability to void, and a distended bladder (Jordan, Jezior & Rosenstein, 2001).
Types and pathophysiologic effects of renal injuries: contusions, lacerations, rupture, and pedicle injury.
The goals of management in patients with genitourinary trauma are to control hemorrhage, pain, and infection; to preserve and restore renal function; and to maintain urinary drainage. In renal trauma, all urine is saved and sent to the laboratory for analysis to detect RBCs and to evaluate the course of bleeding. Hematocrit and hemoglobin levels are monitored closely; decreasing values indicate hemorrhage.
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The patient is monitored for oliguria and signs of hemorrhagic shock because a pedicle injury or shattered kidney can lead to rapid exsanguination (lethal blood loss). An expanding hematoma may cause rupture of the kidney capsule. To detect hematoma, the area around the lower ribs, upper lumbar vertebrae, flank, and abdomen is palpated for tenderness. A palpable flank or abdominal mass with local tenderness, swelling, and ecchymosis suggests renal hemorrhage. The area of the original mass can be outlined with a marking pencil so that the examiner can evaluate the area for change. Renal trauma is often associated with other injuries to the abdominal organs (liver, colon, small intestines); therefore, the patient is assessed for skin abrasions, lacerations, and entry and exit wounds of the upper abdomen and lower thorax because these may be associated with renal injury. With renal trauma, such as a contusion of the kidney, healing may take place with conservative measures. If the patient has microscopic hematuria and a normal intravenous urogram, outpatient management is possible. If gross hematuria or a minor laceration is present, the patient is hospitalized and kept on bed rest until hematuria clears. Antimicrobial medications may be prescribed to prevent infection from perirenal hematoma or urinoma (a cyst containing urine). Patients with retroperitoneal hematomas may develop low-grade fever as absorption of the clot takes place. SURGICAL MANAGEMENT In renal trauma, any sudden change in the patient’s condition may indicate hemorrhage and requires surgical intervention.
!
NURSING ALERT Vital signs, urine output, and level of consciousness are monitored to detect bleeding and shock. Opioid analgesia is avoided because this may mask accompanying abdominal symptoms.
!
NURSING ALERT The patient is prepared for immediate surgery in cases of increasing pulse rate, hypotension, and impending shock.
Depending on the patient’s condition and the nature of the injury, major lacerations may be treated through surgical intervention or conservatively (bed rest, no surgery). Vascular injuries require immediate exploratory surgery because of the high incidence of involvement of other organ systems and the serious complications that may result if these injuries are untreated. The patient is often in shock and requires aggressive fluid resuscitation. The damaged kidney may have to be removed (nephrectomy). Early postoperative complications (within 6 months) include rebleeding, perinephritic abscess formation, sepsis, urine extravasation, and fistula formation. Other complications include stone formation, infection, cysts, vascular aneurysms, and loss of renal function. Hypertension can be a complication of any renal surgery but usually is a late complication of renal injury. In bladder trauma, treatment for rupture of the bladder involves immediate exploratory surgery and repair of the laceration, suprapubic drainage of the bladder and the perivesical space (around the bladder), and insertion of an indwelling urinary catheter. In addition to the usual care following urologic surgery, the drainage systems (suprapubic, indwelling urethral catheter, and perivesical drains) are closely monitored to ensure adequate drainage until healing takes place. The patient with a ruptured bladder may have gross bleeding for several days after repair.
In urethral trauma, unstable patients who need monitoring of urine output may need a suprapubic catheter inserted.
!
NURSING ALERT If blood is seen at the urinary meatus, urethral catheterization should not be attempted until an emergency retrograde urethrogram can be performed.
The patient is catheterized after urethrography is performed to minimize the risk of urethral disruption and extensive, long-term complications, such as stricture, incontinence, and impotence. Surgical repair may be performed immediately or at a later time. Delayed surgical repair tends to be the favored procedure because it is associated with fewer long-term complications, such as impotence, strictures, and incontinence. After surgery, an indwelling urinary catheter may remain in place for up to 1 month.
Nursing Management The patient with genitourinary trauma (particularly renal trauma) should be assessed frequently during the first few days after injury to detect flank and abdominal pain, muscle spasm, and swelling over the flank. During this time, patients can be instructed about care of the incision and the importance of an adequate fluid intake. In addition, instructions about changes that should be reported to the physician, such as fever, hematuria, flank pain, or any signs and symptoms of decreasing kidney function, are provided. Guidelines for increasing activity gradually, lifting, and driving are also provided in accordance with the physician’s prescription. Follow-up nursing care includes monitoring the blood pressure to detect hypertension and advising the patient to restrict activities for about 1 month after trauma to minimize the incidence of delayed or secondary bleeding. The patient should be advised to schedule periodic follow-up assessments of renal function (creatinine clearance, serum BUN and creatinine analyses). If a nephrectomy was necessary, the patient is advised to wear medical identification.
Urinary Tract Cancers The American Cancer Society (2002) estimates increases in both the incidence and death rates of all urinary tract cancers over previous reports; however, while the rate of estimated new cases of bladder cancer has increased, there has been a slight decrease in the rate of new cases of kidney and renal pelvis cancer in the last few years. Urinary tract cancers include those of the urinary bladder, kidney and renal pelvis, ureter, and other urinary structures, such as the prostate. Prostate cancer is discussed in Chapter 49. Tobacco use continues to be a leading cause of all urinary tract cancers.
CANCER OF THE KIDNEY Cancer of the kidney accounts for about 3.7% of all cancers in adults in the United States. It affects almost twice as many men as women. The most common type of renal tumor is renal cell or renal adenocarcinoma, accounting for more than 85% of all kidney tumors (Hock et al., 2002). These tumors may metastasize early to the lungs, bone, liver, brain, and contralateral kidney. One third of patients have metastatic disease at the time of diagnosis. The incidence of all stages of kidney cancer has increased
Chapter 45 in the last two decades in the United States. Although enhanced imaging techniques account for improved detection of early-stage kidney cancer, it is unknown why the rate of late-stage kidney cancers is higher (Hock, Lynch & Balaji, 2002) (Chart 45-13).
Clinical Manifestations Many renal tumors produce no symptoms and are discovered on a routine physical examination as a palpable abdominal mass. The classic triad of signs and symptoms, which occurs in only 10% of patients, comprises hematuria, pain, and a mass in the flank. The usual sign that first calls attention to the tumor is painless hematuria, which may be either intermittent and microscopic or continuous and gross. There may be a dull pain in the back from the pressure produced by compression of the ureter, extension of the tumor into the perirenal area, or hemorrhage into the kidney tissue. Colicky pains occur if a clot or mass of tumor cells passes down the ureter. Symptoms from metastasis may be the first manifestations of renal tumor and may include unexplained weight loss, increasing weakness, and anemia.
Assessment and Diagnostic Findings The diagnosis of a renal tumor may require intravenous urography, cystoscopic examination, nephrotomograms, renal angiograms, ultrasonography, or a CT scan. These tests may be exhausting for patients already debilitated by the systemic effects of a tumor as well as for elderly patients and those who are anxious about the diagnosis and outcome. The nurse assists the patient to prepare physically and psychologically for these procedures and monitors carefully for signs and symptoms of dehydration and exhaustion.
Medical Management The goal of management is to eradicate the tumor before metastasis occurs (Kirkali, Tuzel & Munga, 2002). SURGICAL MANAGEMENT A radical nephrectomy is the preferred treatment if the tumor can be removed. This includes removal of the kidney (and tumor), adrenal gland, surrounding perinephric fat and Gerota’s fascia, and lymph nodes. Radiation therapy, hormonal therapy, or chemotherapy may be used along with surgery. Immunotherapy may also be helpful. For patients with bilateral tumors or cancer of a functional single kidney, nephron-sparing surgery (partial nephrectomy) may be considered. Favorable results have been achieved in patients with small local tumors and a normal contralateral kidney. Nephron-sparing surgery is increasingly being used to treat patients with solid renal lesions. The technical success rate of
Chart 45-13
Risk Factors for Renal Cancer • Gender: Affects men more than women • Tobacco use • Occupational exposure to industrial chemicals, such as petroleum products, heavy metals, and asbestos
• Obesity • Unopposed estrogen therapy • Polycystic kidney disease
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nephron-sparing surgery is excellent, and operative morbidity and mortality are low. For renal cell carcinoma, long-term cancerfree survival is comparable to that after radical nephrectomy, particularly for low-stage disease (Uzzo & Novick, 2001). Although laparoscopic nephroureterectomy is a lengthier surgical procedure, it has the same efficacy and is better tolerated by patients than open nephroureterectomy for upper tract transitional cell carcinoma. As more experience is gained with this type of surgery, surgical time will be reduced (Chen & Bagley, 2000; Jabbour, Desgrandchamps, Cazin et al., 2000; Shalhav, Dunn, Portis et al., 2000). Renal Artery Embolization. In patients with metastatic renal carcinoma, the renal artery may be occluded to impede the blood supply to the tumor and thus kill the tumor cells. After angiographic studies are completed, a catheter is advanced into the renal artery, and embolizing materials (Gelfoam, autologous blood clot, steel coils) are injected into the artery and carried with the arterial blood flow to occlude the tumor vessels mechanically. This decreases the local blood supply, making removal of the kidney (nephrectomy) easier. It also stimulates an immune response because infarction of the renal cell carcinoma releases tumorassociated antigens that enhance the patient’s response to metastatic lesions. The procedure may also reduce the number of tumor cells entering the venous circulation during surgical manipulation. After renal artery embolization and tumor infarction, a characteristic symptom complex called postinfarction syndrome occurs, lasting 2 to 3 days. The patient has pain localized to the flank and abdomen, elevated temperature, and GI symptoms. Pain is treated with parenteral analgesic agents, and acetaminophen is administered to control fever. Antiemetic medications, restriction of oral intake, and intravenous fluids are used to treat the GI symptoms. PHARMACOLOGIC THERAPY Currently, no pharmacologic agents are in widespread use for treating renal cell carcinoma. Depending on the stage of the tumor, percutaneous partial or radical nephrectomy may be followed by treatment with chemotherapeutic agents. The use of biologic response modifiers such as interleukin-2 (IL-2) and topical instillation of bacillus Calmette-Guerin (BCG) in the renal pelvis continue to be studied, with both treatments currently used in clinical practice (Hvarness, Krarup & Eldrup, 2001; Nonomura, Ono, Nozawa et al., 2000; Okubo, Ichioka, Matsuta et al., 2001). Patients may be treated with IL-2, a protein that regulates cell growth. This may be used alone or in combination with lymphokine-activated killer cells, which are WBCs that have been stimulated by IL-2 to increase their ability to kill cancer cells. Interferon, another biologic response modifier, appears to have a direct antiproliferative effect on renal tumors. The study of these biologic agents and new biologic response modifiers is a priority because nearly half of all patients with renal cell carcinoma die within 5 years of diagnosis (Pizza, De Vinci, LoConte et al., 2001).
Nursing Management The patient with a renal tumor usually undergoes extensive diagnostic and therapeutic procedures, including surgery, radiation therapy, and medication (or systemic) therapy. After surgery, the patient usually has catheters and drains in place to maintain a patent urinary tract, to remove drainage, and to permit accurate measurement of urine output. Because of the location of the surgical incision, the position of the patient during surgery, and the
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nature of the surgical procedure, pain and muscle soreness are common. The patient requires frequent analgesia during the postoperative period and assistance with turning. Turning, coughing, use of incentive spirometry, and deep breathing are encouraged to prevent atelectasis and other pulmonary complications. The patient and family require assistance and support to cope with the diagnosis and uncertainties about the prognosis. (See Chap. 44 for a discussion of postoperative care of the patient undergoing kidney surgery and Chap. 16 for discussion of care of the patient with cancer.) PROMOTING HOME AND COMMUNITY-BASED CARE Teaching Patients Self-Care. The patient is taught to inspect and care for the incision and perform other general postoperative care. Additionally, the patient learns about activity and lifting restrictions, driving, and use of pain medications. Instructions are provided about follow-up care and when to notify the physician about problems (fever, breathing difficulty, wound drainage, blood in the urine, pain or swelling of the legs). The patient is encouraged to eat a well-balanced diet and to drink adequate liquids to avoid constipation and to maintain an adequate urine volume. Education and emotional support are provided related to the disease process, treatment plan, and continuing care because many patients are concerned about the loss of the other kidney, the possible need for dialysis, or the recurrence of cancer. Continuing Care. Follow-up care is essential to detect signs of metastases and to reassure the patient and family about the patient’s status and well-being. The patient who has had surgery for renal carcinoma should have a yearly physical examination and chest x-ray because late metastases are not uncommon. All subsequent symptoms should be evaluated with possible metastases in mind. If follow-up chemotherapy is necessary, the patient and family are informed about the entire treatment plan or chemotherapy protocol, what to expect with each visit, and how to notify the physician. Periodic evaluation of remaining renal function (creatinine clearance, serum BUN and creatinine levels) may also be carried out periodically. A home care nurse may monitor the patient’s physical status and psychological well-being and coordinate other services and resources needed by the patient.
CANCER OF THE BLADDER Cancer of the urinary bladder is more common in people aged 50 to 70 years. It affects men more than women (3:1) and is more common in whites than in African Americans. Bladder cancer is the fourth leading cause of cancer in American men, accounting for more than 12,000 deaths in the U.S. annually (American Cancer Society, 2002). Bladder cancer has a high worldwide incidence (Amling, 2001). Bladder tumors account for nearly 1 in 25 cancers diagnosed in the United States. There are two forms of bladder cancer: superficial (which tends to recur) and invasive. About 80% to 90% of all bladder cancers are transitional cell (which means they arise from the transitional cells of the bladder); the remaining types of tumors are squamous cell and adenocarcinoma. Research has demonstrated that many individuals with bladder cancer for which a total cystectomy is required go on to develop upper urinary tract tumors (Amling, 2001; Huguet-Perez, Palui, Millan-Rodriguez et al., 2001).
The predominant cause of bladder cancer today is cigarette smoking. Cancers arising from the prostate, colon, and rectum in males and from the lower gynecologic tract in females may metastasize to the bladder (Chart 45-14).
Clinical Manifestations Bladder tumors usually arise at the base of the bladder and involve the ureteral orifices and bladder neck. Visible, painless hematuria is the most common symptom of bladder cancer. Infection of the urinary tract is a common complication, producing frequency, urgency, and dysuria. Any alteration in voiding or change in the urine, however, may indicate cancer of the bladder. Pelvic or back pain may occur with metastasis.
Assessment and Diagnostic Findings The diagnostic evaluation includes cystoscopy (the mainstay of diagnosis), excretory urography, a CT scan, ultrasonography, and bimanual examination with the patient anesthetized. Biopsies of the tumor and adjacent mucosa are the definitive diagnostic procedures. Transitional cell carcinomas and carcinomas in situ shed recognizable cancer cells. Cytologic examination of fresh urine and saline bladder washings provide information about the prognosis, especially for patients at high risk for recurrence of primary bladder tumors (Amling, 2001). Although mainstay diagnostic tools such as cytology and CT scanning have a high detection rate, they are costly. Newer diagnostic indicators are being studied. Bladder tumor antigens, nuclear matrix proteins, adhesion molecules, cytoskeletal proteins, and growth factors are being studied to support the early detection and diagnosis of bladder cancer. There are an increasing number of molecular assays available for the detection of bladder cancer (Saad, Hanbury, McNicholas et al., 2001).
Medical Management Treatment of bladder cancer depends on the grade of the tumor (the degree of cellular differentiation), the stage of tumor growth (the degree of local invasion and the presence or absence of metastasis), and the multicentricity (having many centers) of the tumor. The patient’s age and physical, mental, and emotional status are considered when determining treatment modalities. SURGICAL MANAGEMENT Transurethral resection or fulguration (cauterization) may be performed for simple papillomas (benign epithelial tumors). These procedures, described in more detail in Chapter 49, eradicate the
Chart 45-14
Risk Factors for Bladder Cancer • Cigarette smoking: risk proportional to number of packs • • • • • • •
smoked daily and number of years of smoking Environmental carcinogens: dyes, rubber, leather, ink, or paint Recurrent or chronic bacterial infection of the urinary tract Bladder stones High urinary pH High cholesterol intake Pelvic radiation therapy Cancers arising from the prostate, colon, and rectum in males
Chapter 45 tumors through surgical incision or electrical current with the use of instruments inserted through the urethra. After this bladdersparing surgery, intravesical administration of BCG is the treatment of choice. Management of superficial bladder cancers presents a challenge because there are usually widespread abnormalities in the bladder mucosa. The entire lining of the urinary tract, or urothelium, is at risk because carcinomatous changes can occur in the mucosa of the bladder, renal pelvis, ureter, and urethra. About 25% to 40% of superficial tumors recur after transurethral resection or fulguration. Patients with benign papillomas should undergo cytology and cystoscopy periodically for the rest of their lives because aggressive malignancies may develop from these tumors. A simple cystectomy (removal of the bladder) or a radical cystectomy is performed for invasive or multifocal bladder cancer. Radical cystectomy in men involves removal of the bladder, prostate, and seminal vesicles and immediate adjacent perivesical tissues. In women, radical cystectomy involves removal of the bladder, lower ureter, uterus, fallopian tubes, ovaries, anterior vagina, and urethra. It may include removal of pelvic lymph nodes. Removal of the bladder requires a urinary diversion procedure. Although radical cystectomy remains the standard of care for invasive bladder cancer in the United States, researchers are exploring trimodality therapy: transurethral resection of the bladder tumor, radiation, and chemotherapy. This is in an effort to spare patients the need for cystectomy. A trimodality approach to transitional cell bladder cancer mandates lifelong surveillance with cystoscopy. Although most completely responding patients retain their bladders free from invasive relapse, one quarter develop superficial disease. This may be managed with transurethral resection of the bladder tumor and intravesical therapies but carries an additional risk that late cystectomy will be required (Zietman, Grocela & Zehr, 2001; Zietman, Shipley & Kaufman, 2000). PHARMACOLOGIC THERAPY Chemotherapy with a combination of methotrexate, 5-fluorouracil, vinblastine, doxorubicin (Adriamycin), and cisplatin has been effective in producing partial remission of transitional cell carcinoma of the bladder in some patients. Intravenous chemotherapy may be accompanied by radiation therapy. The development of new chemotherapeutic agents such as gemcitabine and the taxanes has opened up promising new perspectives in the treatment of bladder cancer. However, the preliminary phase II data must be confirmed in adequately conducted phase III trials (Bellmunt & Albiol, 2001). Topical chemotherapy (intravesical chemotherapy or instillation of antineoplastic agents into the bladder, resulting in contact of the agent with the bladder wall) is considered when there is a high risk for recurrence, when cancer in situ is present, or when tumor resection has been incomplete. Topical chemotherapy delivers a high concentration of medication (thiotepa, doxorubicin, mitomycin, ethoglucid, and BCG) to the tumor to promote tumor destruction. BCG is now considered the most effective intravesical agent for recurrent bladder cancer because it enhances the body’s immune response to cancer. Intravesical BCG is an immunotherapeutic agent that is given intravesically and is effective in the treatment of superficial transitional cell carcinoma. BCG has a 43% advantage in preventing tumor recurrence, a significantly better rate than the 16% to 21% advantage of intravesical chemotherapy. In addition, BCG is particularly effective in the treatment of carcinoma in situ, eradicating it in more than 80% of cases. In contrast to intravesical
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chemotherapy, BCG has also been shown to decrease the risk of tumor progression. The optimal course of BCG appears to be a 6-week course of weekly instillations, followed by a 3-week course at 3 months in tumors that do not respond. In high-risk cancers, maintenance BCG administered for 3 weeks every 6 months may limit recurrence and prevent progression (Amling, 2001). The adverse effects associated with this prolonged therapy, however, may limit its widespread applicability. The patient is allowed to eat and drink before the instillation procedure, but once the bladder is full, the patient must retain the intravesical solution for 2 hours before voiding. At the end of the procedure, the patient is encouraged to void and to drink liberal amounts of fluid to flush the medication from the bladder. RADIATION THERAPY Radiation of the tumor may be performed preoperatively to reduce microextension of the neoplasm and viability of tumor cells, thus reducing the chances that the cancer may recur in the immediate area or spread through the circulatory or lymphatic systems. Radiation therapy is also used in combination with surgery or to control the disease in patients with an inoperable tumor. The transitional cell variety of bladder cancer responds poorly to chemotherapy. Cisplatin, doxorubicin, and cyclophosphamide have been administered in various doses and schedules and appear most effective. Bladder cancer may also be treated by direct infusion of the cytotoxic agent through the bladder’s arterial blood supply to achieve a higher concentration of the chemotherapeutic agent with fewer systemic toxic effects. For more advanced bladder cancer or for patients with intractable hematuria (especially after radiation therapy), a large, water-filled balloon placed in the bladder produces tumor necrosis by reducing the blood supply of the bladder wall (hydrostatic therapy). The instillation of formalin, phenol, or silver nitrate relieves hematuria and strangury (slow and painful discharge of urine) in some patients. INVESTIGATIONAL THERAPY The use of photodynamic techniques in treating superficial bladder cancer is under investigation. This procedure involves systemic injection of a photosensitizing material (hematoporphyrin), which the cancer cell picks up. A laser-generated light then changes the hematoporphyrin in the cancer cell into a toxic medication. This process is being investigated for patients in whom intravesical chemotherapy or immunotherapy has failed (Amling, 2001).
Urinary Diversions Urinary diversion procedures are performed to divert urine from the bladder to a new exit site, usually through a surgically created opening (stoma) in the skin. These procedures are primarily performed when a bladder tumor necessitates removal of the entire bladder (cystectomy). Urinary diversion has also been used in managing pelvic malignancy, birth defects, strictures, trauma to ureters and urethra, neurogenic bladder, chronic infection causing severe ureteral and renal damage, and intractable interstitial cystitis and as a last resort in managing incontinence. Controversy exists about the best method of establishing permanent diversion of the urinary tract. New techniques are frequently introduced in an effort to improve patient outcomes and quality of life. The age of the patient, condition of the bladder, body build, degree of obesity, degree of ureteral dilation, status of renal function, and the patient’s learning ability and willingness
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to participate in postoperative care are all taken into consideration when determining the appropriate surgical procedure. Creating a reliable continence mechanism for a continent reservoir is a great challenge. The ability of urinary diversions to be continent devices for both ease of emptying and better quality of life has been the focus of research during recent years (Abol-Enein & Ghoneim, 2001; Deliveliotis, Alargoff, Skolarikos et al., 2001; Kane, 2000; Yachia & Erlich, 2001; Zinman, 1999). The extent to which the patient accepts urinary diversion depends to a large degree on the location or position of the stoma, whether the drainage device (pouch or bag) establishes a watertight seal to the skin, and the patient’s ability to manage the pouch and drainage apparatus. Paying attention to these considerations helps to promote a positive outcome (Kane, 2000).
There are two categories of urinary diversion: cutaneous urinary diversion, in which urine drains through an opening created in the abdominal wall and skin (Fig. 45-9), and continent urinary diversion, in which a portion of the intestine is used to create a new reservoir for urine (Fig. 45-10).
CUTANEOUS URINARY DIVERSIONS Ileal Conduit (Ileal Loop) The ileal conduit, the oldest of the urinary diversion procedures, is considered the gold standard because of the low number of complications and surgeons’ familiarity with the procedure. In an ileal conduit, the urine is diverted by implanting the ureter into
Ileal segment
Conventional ileal conduit. The surgeon transplants the ureters to an isolated section of the terminal ileum (ileal conduit), bringing one end to the abdominal wall. The ureter may also be transplanted into the transverse sigmoid colon (colon conduit) or proximal jejunum (jejunal conduit).
Vesicostomy. The surgeon sutures the bladder to the abdominal wall and creates an opening (stoma) through the abdominal and bladder walls for urinary drainage.
Cutaneous ureterostomy. The surgeon brings the detached ureter through the abdominal wall and attaches it to an opening in the skin.
Nephrostomy. The surgeon inserts a catheter into the renal pelvis via an incision into the flank or, by percutaneous catheter placement, into the kidney.
FIGURE 45-9 Types of cutaneous diversions include (A) the conventional ileal conduit, (B) cutaneous ureterostomy, (C) vesicostomy, and (D) nephrostomy.
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Stoma
Koch pouch
Indiana pouch Stoma
A
B
Indiana pouch. The surgeon introduces the ureters into a segment of ileum and cecum. Urine is drained periodically by inserting a catheter into the stoma.
Continent ileal urinary diversions (Koch pouch). The surgeon transplants the ureters to an isolated segment of small bowel, ascending colon, or ileocolonic segment and develops an effective continence mechanism or valve. Urine is drained by inserting a catheter into the stoma.
Transverse colon
Sigmoid colon
C
FIGURE 45-10
Types of continent urinary diversions include (A) the Indiana pouch, (B and C) the Koch pouch, also called a continent ileal diversion, and (D) a ureterosigmoidostomy.
Juncture of pouch and urethra
In male patients, the Koch pouch can be modified by attaching one end of the pouch to the urethra, allowing more normal voiding. The female urethra is too short for this modification.
a 12-cm loop of ileum that is led out through the abdominal wall. This loop of ileum is a simple conduit (passageway) for urine from the ureters to the surface. A loop of the sigmoid colon may also be used. An ileostomy bag is used to collect the urine. The resected (cut) ends of the remaining intestine are anastomosed (connected) to provide an intact bowel. Stents, usually made of thin, pliable tubing, are placed in the ureters to prevent occlusion secondary to postsurgical edema. The bilateral ureteral stents allow urine to drain from the kidney to the stoma and provide a method for accurate measurement of urine output. They may be left in place 10 to 21 days postoperatively. Jackson-Pratt tubes or other types of drains are inserted to prevent the accumulation of fluid in the space created by removal of the bladder. After surgery, a skin barrier and a transparent, disposable urinary drainage bag are applied around the conduit and connected to drainage. A custom-cut appliance is used until the edema subsides and the stoma shrinks to normal size. The clear bag allows the stoma to be seen and the patency of the stent and the urine output to be monitored. The ileal bag drains urine constantly
Rectum
D Ureterosigmoidostomy. The surgeon introduces the ureters into the sigmoid, thereby allowing urine to flow through the colon and out of the rectum.
(not feces). The appliance (bag) usually remains in place as long as it is watertight; it is changed when necessary to prevent leakage of urine. Complications that may follow placement of an ileal conduit include wound infection or wound dehiscence, urinary leakage, ureteral obstruction, hyperchloremic acidosis, small bowel obstruction, ileus, and stomal gangrene. Delayed complications include ureteral obstruction, contraction or narrowing of the stoma (stomal stenosis), renal deterioration due to chronic reflux, pyelonephritis, and renal calculi.
Nursing Management In the immediate postoperative period, urine volumes are monitored hourly. An output below 30 mL/h may indicate dehydration or an obstruction in the ileal conduit, with possible backflow or leakage from the ureteroileal anastomosis. Throughout the patient’s hospitalization, the nurse monitors closely for complications, reports signs and symptoms of them promptly, and intervenes quickly to prevent their progression.
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PROMOTING URINE OUTPUT A catheter may be inserted through the urinary conduit if prescribed to monitor the patient for possible stasis or residual urine from a constricted stoma. Urine may drain through the bilateral ureteral stents as well as around the stents. If the ureteral stents are not draining, the nurse may be instructed to irrigate them with 5 to 10 mL of sterile normal saline solution. It is important to avoid any tension on the stents because this may dislodge them. Hematuria may be noted in the first 48 hours after surgery but usually resolves spontaneously. PROVIDING STOMA AND SKIN CARE Because the patient requires specialized care, a consultation is initiated with an enterostomal therapist or clinical nurse specialist in skin care. The stoma is inspected frequently for color and viability. A healthy stoma is beefy red. A change from this normal color to a dark purplish color suggests that the vascular supply may be compromised. If cyanosis and a compromised blood supply persist, surgical intervention may be necessary. The stoma is not sensitive to touch, but the skin around the stoma becomes sensitive if urine or the appliance irritates it. The skin is inspected for (1) signs of irritation and bleeding of the stomal mucosa, (2) encrustation and skin irritation around the stoma (from alkaline urine coming in contact with exposed skin), and (3) wound infections. TESTING URINE AND CARING FOR THE OSTOMY Moisture in bed linens or clothing or the odor of urine around the patient should alert the nurse to the possibility of leakage from the appliance, potential infection, or a problem in hygienic management. Because severe alkaline encrustation can accumulate rapidly around the stoma, the urine pH is kept below 6.5 by administration of ascorbic acid by mouth. Urine pH can be determined by testing the urine draining from the stoma, not from the collecting appliance. A properly fitted appliance is essential to prevent exposure of the peristomal skin (skin around the stoma) to urine. If the urine is foul-smelling, the stoma is catheterized, if prescribed, to obtain a urine specimen for culture and sensitivity testing. ENCOURAGING FLUIDS AND RELIEVING ANXIETY Because mucous membrane is used in forming the conduit, the patient may excrete a large amount of mucus mixed with urine. This causes many patients to feel anxious. To help relieve this anxiety, the nurse reassures the patient that this is a normal occurrence after an ileal conduit procedure. The nurse encourages adequate fluid intake to flush the ileal conduit and decrease the accumulation of mucus. SELECTING THE OSTOMY APPLIANCE Various urine collection appliances are available, and the nurse is instrumental in selecting an appropriate one. The urinary appliance may consist of one or two pieces and may be disposable (usually used once and discarded) or reusable. The choice of appliance is determined by the location of the stoma and by the patient’s normal activity, manual dexterity, visual function, body build, economic resources, and preference.
!
NURSING ALERT All patients should be assessed for possible latex allergy. Latex appliances and drainage systems must not be used with patients with known or suspected latex allergy.
A reusable appliance has a faceplate that is attached to the skin surface with cement or adhesive. Either reusable pouches or disposable pouches may be used with the reusable faceplate. Disposable appliances have the advantages of having a surface that is already prepared for application to the skin and of being lightweight and easy to conceal. A skin barrier must be used to protect the skin from excoriation due to exposure to the urine. PROMOTING HOME AND COMMUNITY-BASED CARE Teaching Patients Self-Care. Patient education begins in the hospital but continues into the home setting because patients are usually discharged within days of surgery. The nurse teaches the patient how to assess and manage the urinary diversion as well as how to deal with body image changes. An enterostomal therapist is invaluable in consulting with the nurse on various aspects of care and patient education. Changing the Appliance. The patient and family are taught to apply and change the appliance so that they are comfortable carrying out the procedure and can do so proficiently. Ideally, the appliance system is changed before the system leaks and at a time that is convenient for the patient. Many patients find early morning most convenient because the urine output is reduced. A variety of appliances are available; an average collecting appliance lasts 3 to 7 days before leakage occurs. Regardless of the type of appliance used, a skin barrier is essential to protect the skin from irritation and excoriation. To maintain peristomal skin integrity, a skin barrier or leaking pouch is never patched with tape to prevent accumulation of urine under the skin barrier or faceplate. The patient is instructed to avoid moisturizing soaps when cleaning the area because they interfere with the adhesion of the pouch. Because the degree to which the stoma protrudes is not the same in all patients, there are various accessories and custom-made appliances to solve individual problems. Guidelines for applying reusable and disposable systems are presented in Chart 45-15. Controlling Odor. The patient is instructed to avoid foods that give the urine a strong odor (eg, asparagus, cheese, eggs). Today, most appliances contain odor barriers, but a few drops of liquid deodorizer or diluted white vinegar may be introduced through the drain spout into the bottom of the pouch with a syringe or eyedropper to reduce odors. Ascorbic acid by mouth helps acidify the urine and suppress urine odor. Patients should be cautioned about putting aspirin tablets in the pouch to control odor because they may ulcerate the stoma. Also, the patient is reminded that odor will develop if the pouch is worn too long and not cared for properly. Managing the Ostomy Appliance. The patient is instructed to empty the pouch by means of a drain valve when it is one-third full because the weight of the urine will cause the pouch to separate from the skin if filled more. Some patients prefer wearing a leg bag attached with an adapter to the drainage apparatus. To promote uninterrupted sleep, a collecting bottle and tubing (one unit) are snapped onto an adapter that connects to the ileal appliance. A small amount of urine is left in the bag when the adapter is attached to prevent the bag from collapsing against itself. The tubing may be threaded down the pajama or pants leg to prevent kinking. The collecting bottle and tubing are rinsed daily with cool water and once a week with a 3:1 solution of water and white vinegar. Cleaning and Deodorizing the Appliance. Usually, the reusable appliance is rinsed in warm water and soaked in a 3⬊1 solution of water and white vinegar or a commercial deodorizing solution for
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Chart 45-15
• PATIENT EDUCATION Using Urinary Diversion Collection Appliances Applying a Reusable Pouch System 1. Gather all necessary supplies. 2. Prepare new appliance according to the manufacturer’s directions. • Apply double-faced adhesive disk that has been properly sized to fit the reusable pouch faceplate. Remove paper backing and lay pouch aside. or: • Apply thin layer of contact cement to one side of the reusable pouch faceplate. Lay pouch aside. 3. Remove soiled pouch gently. Lay aside to clean later. 4. Clean peristomal skin with small amount of soap and water. Rinse thoroughly and dry. If a film of soap remains on the skin and the site does not dry, the appliance will not adhere adequately. 5. Use a wick (rolled gauze pad or tampon) on top of the stoma to absorb urine and keep the skin dry throughout the appliance change. 6. Inspect peristomal skin (skin around stoma) for irritation. 7. A skin protector wipe or barrier ring may be applied before centering the faceplate opening directly over the stoma. 8. Position appliance over stoma and press gently into place. 9. If desired, use a pouch cover or apply cornstarch under the pouch to prevent perspiration and skin irritation. 10. Clean soiled pouch and prepare for reuse.
8. Center opening of skin barrier over stoma and apply with firm, gentle pressure to attain a watertight seal. 9. If using a two-piece system, snap pouch onto the flanged wafer that adheres to skin. 10. Close drainage tap or spout at bottom of pouch. 11. A pouch cover can be used or cornstarch applied under pouch to prevent perspiration and skin irritation. 12. Apply hypoallergenic tape around the skin barrier in a pictureframe manner. 13. Dispose of soiled appliance.
Applying a Disposable Pouch System 1. Gather all necessary supplies. 2. Measure stoma and prepare an opening in the skin barrier about an 1⁄8-inch larger than the stoma and the same shape as the stoma. 3. Remove paper backing from skin barrier and set aside. 4. Gently remove old appliance and set aside. 5. Clean peristomal skin with warm water and dry thoroughly. 6. Inspect peristomal skin (skin around stoma) for irritation. 7. Use a wick (rolled gauze pad or tampon) on top of the stoma to absorb urine and keep the skin dry during the appliance change.
30 minutes. It is rinsed with tepid water and air-dried away from direct sunlight. (Hot water and exposure to direct sunlight dry the pouch and increase the incidence of cracking.) After drying, the appliance may be powdered with cornstarch and stored. Two appliances are necessary—one to be worn while the other is airdrying. Continuing Care. Follow-up care is essential to determine how the patient has adapted to the body image changes and lifestyle changes. Referral for home care is indicated to determine how well the patient and family are coping with the changes necessitated by altered urinary drainage. The home care nurse assesses the patient’s physical status and emotional response to urinary diversion. Additionally, the nurse assesses the ability of the patient and family to manage the urinary diversion and appliance, reinforces previous teaching, and provides additional information (eg, community resources, sources of ostomy supplies, insurance coverage for supplies). As the postoperative edema subsides, the home care nurse assists in determining the appropriate changes needed in the ostomy appliance. The stoma opening is recalibrated every 3 to 6 weeks for the first few months postoperatively. The correct appliance size is determined by measuring the widest part of the stoma with a ruler. The permanent appliance should be no more
than 1.6 mm (1⁄8 inch) larger than the diameter of the stoma and the same shape as the stoma to prevent contact of the skin with drainage. The nurse encourages the patient and family to contact the United Ostomy Association and local ostomy association for visits, reassurance, and practical information. In addition, the local division of the American Cancer Society can provide medical equipment and supplies and other resources for the patient who has undergone ostomy surgery for cancer. The home care nurse also assesses the patient for potential long-term complications, such as ureteral obstruction, stomal stenosis, hernias, or deterioration of renal function, and reinforces previous teaching about these complications. The nurse also needs to remind the patient who has had surgery for carcinoma to have a yearly physical examination and chest x-ray to assess for metastases. Periodic evaluation of remaining renal function (creatinine clearance, serum BUN and creatinine levels) is also essential. Long-term monitoring for anemia is performed to identify a vitamin B deficiency that may occur when a significant portion of the terminal ileum is removed. This may take several years to develop and can be treated with vitamin B injections. Additionally, the patient is reminded of the importance of participating in health promotion activities and recommended health screening.
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Cutaneous Ureterostomy A cutaneous ureterostomy (see Fig. 45-9), in which the ureters are directed through the abdominal wall and attached to an opening in the skin, is used for selected patients with ureteral obstruction (advanced pelvic cancer); for poor-risk patients, because it requires less extensive surgery than other urinary diversion procedures; and for patients who have had previous abdominal irradiation. A urinary appliance is fitted immediately after surgery. The management of the patient with a cutaneous ureterostomy is similar to the care of the patient with an ileal conduit, although the stomas are usually flush with the skin or retracted.
Other Cutaneous Urinary Diversions Other cutaneous urinary diversions are used less frequently and are most often used to bypass obstructions. Suprapubic bladder drainage (cystostomy) and nephrostomy are discussed further in Chapter 44.
CONTINENT URINARY DIVERSIONS Continent Ileal Urinary Reservoir (Indiana Pouch) The most common continent urinary diversion is the Indiana pouch, created for patients whose bladder is removed or can no longer function (neurogenic bladder). The Indiana pouch uses a
segment of the ileum and cecum to form the reservoir for urine (see Fig. 45-10A). The ureters are tunneled through the muscular bands of the intestinal pouch and anastomosed. The reservoir is made continent by narrowing the efferent portion of the ileum and sewing the terminal ileum to the subcutaneous tissue, forming a continent stoma flush with the skin. The pouch is sewn to the anterior abdominal wall around a cecostomy tube. Urine can collect in the pouch until a catheter is inserted and the urine is drained. The pouch must be drained at regular intervals by a catheter to prevent absorption of metabolic waste products from the urine, reflux of urine to the ureters, and UTI. Postoperative nursing care of the patient with a continent ileal urinary pouch is similar to nursing care of the patient with an ileal conduit. However, these patients usually have additional drainage tubes (cecostomy catheter from the pouch, stoma catheter exiting from the stoma, ureteral stents, Penrose drain, as well as a urethral catheter), as depicted in Figure 45-11. All drainage tubes must be carefully monitored for patency and amount and type of drainage. The cecostomy tube is irrigated two or three times daily to remove mucus from the pouch and prevent blockage. Other variations of continent urinary reservoirs include the Kock pouch (U-shaped pouch constructed of ileum, with a nipplelike one-way valve; see Fig. 45-10B and C ) and the Charleston pouch (uses the ileum and ascending colon as the pouch, with the appendix and colon junction serving as the one-way valve mechanism). With both of these methods, the pouch must be drained at regular intervals by a catheter.
Line of incision Penrose drain Urethral catheter
Collection bags for drainage from ureteral stents and for bile
Stomal catheter drainage
Cecostomy catheter
FIGURE 45-11 After surgery to create a continent ileal urinary reservoir (Indiana pouch), the patient will have many drains and catheter devices in place.
Chapter 45 Ureterosigmoidostomy Ureterosigmoidostomy, another form of continent urinary diversion, is an implantation of the ureters into the sigmoid colon (see Fig. 45-10D). It is usually performed in patients who have had extensive pelvic irradiation, previous small bowel resection, or coexisting small bowel disease. After surgery, voiding occurs from the rectum (for life), and an adjustment in lifestyle will be necessary because of urinary frequency (as often as every 2 hours). Drainage has a consistency equivalent to watery diarrhea, and the patient has some degree of nocturia. Patients usually need to plan activities around the frequent need to urinate, which in turn may affect the patient’s social life. Patients have the advantage, however, of urinary control without having to wear an external appliance.
Nursing Management In addition to the usual preoperative regimen, the patient may be placed on a liquid diet for several days preoperatively to reduce residue in the colon. Antibiotic agents (neomycin, kanamycin) are administered to disinfect the bowel. Ureterosigmoidostomy requires a competent anal sphincter, adequate renal function, and active renal peristalsis. The degree of anal sphincter control may be determined by assessing the patient’s ability to retain enemas. The postoperative regimen initially includes placing a catheter in the rectum to drain the urine and prevent reflux of urine into the ureters and kidneys. The tube is taped to the buttocks, and special skin care is given around the anus to prevent excoriation. Irrigations of the rectal tube may be prescribed, but force is never used because of the danger of introducing bacteria into the newly implanted ureters. MONITORING FLUID AND ELECTROLYTES In ureterosigmoidostomy, larger areas of the bowel mucosa are exposed to urine and electrolyte reabsorption. As a result, electrolyte imbalance and acidosis may occur. Potassium and magnesium in the urine may cause diarrhea. Fluid and electrolyte balance is maintained in the immediate postoperative period by closely monitoring the serum electrolyte levels and administering appropriate intravenous infusions. Acidosis may be prevented by placing the patient on a low-chloride diet supplemented with sodium potassium citrate. The patient should be instructed never to wait longer than 2 to 3 hours before emptying urine from the intestine. This keeps rectal pressure low and minimizes the absorption of urinary constituents from the colon. It is essential to teach the patient about the symptoms of UTI: fever, flank pain, and frequency. RETRAINING THE ANAL SPHINCTER After the rectal catheter is removed, the patient learns to control the anal sphincter through special sphincter exercises. At first, urination is frequent. With reassurance and encouragement and the passage of time, the patient gains greater control and learns to differentiate between the need to void and the need to defecate. PROMOTING DIETARY MEASURES Specific dietary instructions include avoidance of gas-forming foods (flatus can cause stress incontinence and offensive odors). Other ways to avoid gas are to avoid chewing gum, smoking, and any other activity that involves swallowing air. Salt intake may be restricted to prevent hyperchloremic acidosis. Potassium intake is increased through foods and medication because potassium may be lost in acidosis.
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MONITORING AND MANAGING POTENTIAL COMPLICATIONS Pyelonephritis (upper UTI) due to reflux of bacteria from the colon is fairly common. Long-term antibiotic therapy may be prescribed to prevent infection. A late complication is adenocarcinoma of the sigmoid colon, possibly from cellular changes due to exposure of the colonic mucosa to urine. Urinary carcinogens promote late malignant transformation of the colon after a ureterosigmoidostomy. Therefore, diligent patient teaching regarding the need for life-long medical followup is essential (Guy et al, 2001; Huang & McPherson, 2000).
OTHER URINARY DIVERSION PROCEDURES Variations on urinary diversion surgical procedures are devised frequently in an effort to identify and perfect procedures that will improve patient outcomes and reduce the incidence of postoperative problems. These include cecal, patched cecal, and Mainz reservoirs. These techniques involve isolating a part of the large intestine to form a reservoir for urine and creating an abdominal stoma. Another surgical procedure, the Camey procedure, uses a portion of the ileum as a bladder substitute. In this procedure, the isolated ileum serves as the reservoir for urine; it is anastomosed directly to the portion of the remaining urethra after cystectomy. This procedure permits emptying of the bladder through the urethra. The Camey procedure, however, applies only to men because the entire urethra is removed when a cystectomy is performed in women.
NURSING PROCESS: THE PATIENT UNDERGOING URINARY DIVERSION SURGERY Preoperative Assessment The following are key preoperative nursing assessment concerns:
• Cardiopulmonary function assessments are performed be-
• •
cause patients undergoing cystectomy (excision of the urinary bladder) are often older people who may not be able to tolerate a lengthy, complex surgical procedure. A nutritional status assessment is important because of possible poor nutritional intake related to underlying health problems. Learning needs are assessed to evaluate the patient’s and the family’s understanding of the procedure and the changes in physical structure and function that result from the surgery. The patient’s self-concept and self-esteem are assessed, in addition to methods for coping with stress and loss. The patient’s mental status, manual dexterity and coordination, and preferred method of learning are noted because they will affect postoperative self-care.
Preoperative Nursing Diagnoses Based on the assessment data, the preoperative nursing diagnoses for the patient undergoing urinary diversion surgery may include the following:
• Anxiety related to anticipated losses associated with the surgical procedure
• Imbalanced nutrition, less than body requirements related to inadequate nutritional intake
• Deficient knowledge about the surgical procedure and postoperative care
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Preoperative Planning and Goals The major goals for the patient may include relief of anxiety, improved preoperative nutritional status, and increased knowledge about the surgical procedure, expected outcomes, and postoperative care.
Preoperative Nursing Interventions RELIEVING ANXIETY The threat of cancer and removal of the bladder create fears related to body image and security. The patient faces problems in adapting to an external appliance, a stoma, a surgical incision, and altered toileting habits. The male patient must also adapt to sexual impotency. (A penile implant is considered if the patient is a candidate for the procedure.) Women also fear altered appearance, body image, and self-esteem. A supportive approach, both physical and psychosocial, is needed and includes assessing the patient’s self-concept and manner of coping with stress and loss; helping the patient to identify ways to maintain his or her lifestyle and independence with as few changes as possible; and encouraging the patient to express fears and anxieties about the ramifications of the upcoming surgery. A visitor from the Ostomy Visitation Program of the American Cancer Society can provide emotional support and make adaptation easier both before and after surgery. ENSURING ADEQUATE NUTRITION In addition to cleansing the bowel to minimize fecal stasis, decompress the bowel, and minimize postoperative ileus, a low-residue diet is prescribed and antibiotic medications are administered to reduce pathogenic flora in the bowel and to reduce the risk of infection. Because the patient undergoing a urinary diversion procedure for cancer may be severely malnourished due to the tumor, radiation enteritis, and anorexia, enteral or parenteral nutrition may be prescribed to promote healing. Adequate preoperative hydration is imperative to ensure urine flow during surgery and to prevent hypovolemia during the prolonged surgical procedure. EXPLAINING SURGERY AND ITS EFFECTS An enterostomal therapist is invaluable in preoperative teaching and in planning postoperative care. Explanations of the surgical procedure, the appearance of the stoma, the rationale for preoperative bowel preparation, the reasons for wearing a collection device, and the anticipated effects of the surgery on sexual functioning are part of patient teaching. The placement of the stoma site is planned preoperatively with the patient standing, sitting, or lying down to locate the stoma away from bony prominences, skin creases, and fat folds. The stoma should also be placed away from old scars, the umbilicus, and the belt line. For ease of self-care, the patient must be able to see and reach the site comfortably. The site is marked with indelible ink so that it can be located easily during surgery. The patient is assessed for allergies or sensitivity to tape or adhesives. (Patch testing of certain appliances may be necessary before the ostomy equipment is selected. This is particularly important if the patient may be or is allergic to latex.) It may be helpful to have the patient practice wearing an appliance partially filled with water before surgery (Krupski & Theodorescu, 2001).
EXPECTED PATIENT OUTCOMES Expected patient outcomes may include: 1. Exhibits reduced anxiety about surgery and expected losses a. Verbalizes fears with health care team and family b. Expresses positive attitude about outcome of surgery 2. Exhibits adequate nutritional status a. Maintains adequate intake before surgery b. Maintains body weight c. States rationale for enteral or parenteral nutrition if needed d. Exhibits normal skin turgor, moist mucous membranes, adequate urine output, and absence of excessive thirst 3. Demonstrates knowledge about the surgical procedure and postoperative course a. Identifies limitations expected after surgery b. Discusses expected immediate postoperative environment (tubes, machines, nursing surveillance) c. Practices deep breathing, coughing, and foot exercises
Postoperative Assessment The role of the nurse in the immediate postoperative period is to prevent complications and to assess the patient carefully for any signs and symptoms of complications. The catheters and any drainage devices are monitored closely. Urine volume, patency of the drainage system, and color of the drainage are assessed. A sudden decrease in urine volume or increase in drainage is reported promptly to the physician because these may indicate obstruction of the urinary tract, inadequate blood volume, or bleeding. In addition, the patient’s needs for pain control are assessed (Colwell, Goldberg & Cramel, 2001).
Postoperative Diagnosis NURSING DIAGNOSES Based on the assessment data, the major postoperative nursing diagnoses for the patient following urinary diversion surgery may include the following:
• Risk for impaired skin integrity related to problems in managing the urine collection appliance
• Acute pain related to surgical incision • Disturbed body image related to urinary diversion • Potential for sexual dysfunction related to structural and physiologic alterations
• Deficient knowledge about management of urinary function Collaborative Problems/ Potential Complications Potential complications may include the following:
• Peritonitis due to disruption of anastomosis • Stomal ischemia and necrosis due to compromised blood supply to stoma
• Stoma retraction and separation of mucocutaneous border due to tension or trauma
Preoperative Evaluation
Postoperative Planning and Goals
To measure the effectiveness of care, the nurse evaluates the preoperative patient’s anxiety level and nutritional status as well as his or her knowledge and expectations of surgery.
The major goals for the patient may include maintaining peristomal skin integrity, relieving pain, increasing self-esteem, developing appropriate coping mechanisms to accept and deal with
Chapter 45 altered urinary function and sexuality, increasing knowledge about management of urinary function, and preventing potential complications (Krupski & Theodorescu, 2001; O’Shea, 2001).
Postoperative Nursing Interventions Postoperative management focuses on monitoring urinary function, preventing postoperative complications (infection and sepsis, respiratory complications, fluid and electrolyte imbalances, fistula formation, and urine leakage), and promoting patient comfort. Catheters or drainage systems are observed, and urine output is monitored carefully. A nasogastric tube is inserted during surgery to decompress the GI tract and to relieve pressure on the intestinal anastomosis. It is usually kept in place for several days after surgery. As soon as bowel function resumes, as indicated by bowel sounds, the passage of flatus, and a soft abdomen, oral fluids are permitted. Until that time, intravenous fluids and electrolytes are administered. The patient is assisted to ambulate as soon as possible to prevent complications of immobility. MAINTAINING PERISTOMAL SKIN INTEGRITY Strategies to promote skin integrity begin with reducing and controlling those factors that increase the patient’s risk for poor nutrition and poor healing. As indicated previously, meticulous skin care and management of the drainage system are provided by the nurse until the patient can manage them and is comfortable doing so. Care is taken to keep the drainage system intact to protect the skin from exposure to drainage. Supplies must be readily available to manage the drainage in the immediate postoperative period. Consistency in implementing the skin care program throughout the postoperative period will result in maintenance of skin integrity and patient comfort. Additionally, maintenance of skin integrity around the stoma will enable the patient and family to adjust more easily to the alterations in urinary function and will help them to learn skin care techniques. RELIEVING PAIN Analgesic medications are administered liberally postoperatively to relieve pain and promote comfort, thereby allowing the patient to turn, cough, and do deep-breathing exercises. Patient-controlled analgesia and administration of analgesic agents regularly around the clock are two options that may be used to ensure adequate pain relief. A pain-intensity scale is used to evaluate the adequacy of the medication and the approach to pain management. IMPROVING BODY IMAGE The patient’s ability to cope with the changes associated with the surgery depends to some degree on his or her body image and selfesteem before the surgery and the support and reaction of others. Allowing the patient to express concerns and anxious feelings can help, especially in adjusting to the changes in toileting habits. The nurse can also help improve the patient’s self-concept by teaching the skills needed to be independent in managing the urinary drainage devices. Education about ostomy care is conducted in a private setting to encourage the patient to ask questions without fear of embarrassment. Explaining why the nurse must wear gloves when performing ostomy care can prevent the patient from misinterpreting the use of gloves as a sign of aversion to the stoma. EXPLORING SEXUALITY ISSUES Patients who experience altered sexual function as a result of the surgical procedure may mourn for this loss. Encouraging the pa-
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tient and partner to share their feelings about this loss with each other and acknowledging the importance of sexual function and expression may encourage the patient and partner to seek sexual counseling and to explore alternative ways of expressing sexuality. A visit from another “ostomate” who is functioning fully in society and family life may also assist the patient and family in recognizing that full recovery is possible. MONITORING AND MANAGING POTENTIAL COMPLICATIONS Complications are not unusual because of the complexity of the surgery, the underlying reason (cancer, trauma) for the urinary diversion procedure, and the patient’s frequently less-than-optimal nutritional status. Complications may include the usual postoperative complications (eg, respiratory problems, such as atelectasis, fluid and electrolyte imbalances) as well as breakdown of the anastomoses, sepsis, fistula formation, fecal or urine leakage, and skin irritation. If these occur, the patient will remain hospitalized for an extended length of time and will probably require parenteral nutrition, GI decompression by means of nasogastric suction, and further surgery. The goals of management are to establish drainage, provide adequate nutrition for healing to occur, and prevent sepsis. Peritonitis Peritonitis can occur postoperatively if urine leaks at the anastomosis. Signs and symptoms include abdominal pain and distention, muscle rigidity with guarding, nausea and vomiting, paralytic ileus (absence of bowel sounds), fever, and leukocytosis. Urine output must be monitored closely because a sudden decrease in amount with a corresponding increase in drainage from the incision or drains may indicate urine leakage. In addition, the urine drainage device is observed for leakage. The pouch is changed if a leak is observed. Small leaks in the anastomosis may seal themselves, but surgery may be needed for larger leaks. Vital signs (blood pressure, pulse and respiratory rates, temperature) are monitored. Changes in vital signs, as well as increasing pain, nausea and vomiting, and abdominal distention, are reported to the physician and may indicate peritonitis. Stomal Ischemia and Necrosis The stoma is monitored because stomal ischemia and necrosis can result from tension on the mesentery blood vessels, twisting of the bowel segment (conduit) during surgery, or arterial insufficiency. The new stoma must be inspected at least every 4 hours to assess the adequacy of its blood supply. The stoma should be red or pink. If the blood supply to the stoma is compromised, the color changes to purple, brown, or black. These changes are reported immediately to the physician. The physician or enterostomal therapist may insert a small, lubricated tube into the stoma and shine a flashlight into the lumen of the tube to assess for superficial ischemia or necrosis. A necrotic stoma requires surgical intervention. If the ischemia is superficial, the dusky stoma is observed and may slough its outer layer in several days. Stomal Retraction and Separation Stoma retraction and separation of the mucocutaneous border can occur as a result of trauma or tension on the internal bowel segment used for creation of the stoma. In addition, mucocutaneous separation can occur if the stoma does not heal as a result of accumulation of urine on the stoma and mucocutaneous border. Using a collection drainage pouch with an antireflux valve is helpful because the valve prevents urine from pooling on the
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stoma and mucocutaneous border. Meticulous skin care to keep the area around the stoma clean and dry promotes healing. If a separation of the mucocutaneous border occurs, surgery is not usually needed. The separated area is protected by applying karaya powder, stoma adhesive paste, and a properly fitted skin barrier and pouch. By protecting the separation, healing is promoted. If the stoma retracts into the peritoneum, surgical intervention is mandatory. If surgery is needed to manage these complications, the nurse provides explanations to the patient and family. The need for additional surgery is usually perceived as a setback by the patient and family. Emotional support of the patient and family is provided along with physical preparation of the patient for surgery. PROMOTING HOME AND COMMUNITY-BASED CARE Teaching Patients Self-Care A major postoperative objective is to assist the patient to achieve the highest level of independence and self-care possible. The primary nurse and enterostomal therapist work closely with the patient and family to instruct and assist them in all phases of managing the ostomy. Adequate supplies and complete instruction are necessary to enable the patient and a family member to develop competence and confidence in their skills. Written and verbal instructions are provided, and the patient is encouraged to contact the nurse or physician with follow-up questions. Followup telephone calls from the nurse to the patient and family after discharge may provide added support and provide another opportunity to answer their questions. Follow-up visits and reinforcement of correct skin care and appliance management techniques also promote skin integrity. Specific techniques for managing the appliance are described in Chart 45-15. The patient is encouraged to participate in decisions regarding the type of collecting appliance and the time of day to change the appliance. The patient is assisted and encouraged to look at and touch the stoma early to overcome any fears. The patient and family need to know the characteristics of a normal stoma, as follows:
• Pink and moist, like the inside of the mouth • Insensitive to pain because it has no nerve endings • Vascular and may bleed when cleaned Additionally, if a segment of the GI tract was used to create the urinary diversion, mucus may be visible in the urine. By learning what is normal, the patient and family become familiar with what signs and symptoms they should report to the physician or nurse and what problems they can handle themselves. Information provided to the patient and the extent of involvement in self-care are determined by the patient’s physical recovery and ability to accept and acquire the knowledge and skill needed for independence. Verbal and written instructions are provided, and the patient is given the opportunity to practice and demonstrate the knowledge and skills needed to manage urinary drainage. Continuing Care Follow-up care is essential to determine how the patient has adapted to the body image changes and lifestyle adjustments. Visits from a home care nurse are important to assess the patient’s adaptation to the home setting and management of the ostomy. Teaching and reinforcement may assist the patient and family to cope with altered urinary function. It is also necessary to assess for long-term complications that may occur, such as pouch leakage
or rupture, stone formation, stomal stenosis, deterioration in renal function, or incontinence (Baker, 2001). The following procedures are recommended for patients with a continent urinary diversion: pouch-o-gram (x-rays taken after a radioactive agent is instilled into the pouch) between 3 and 6 months, 9 and 12 months, 24 months, then every other year; renal function tests (BUN, serum creatinine) 1 month, 3 months, 6 months, then twice yearly; and pouchoscopy (endoscopic examination of the pouch) every year starting 5 to 7 years after surgery (Colwell, Goldberg & Cramel, 2001). The patient who has had surgery for carcinoma should have a yearly physical examination and chest x-ray to assess for metastases. In addition, the patient and family are reminded of the importance of participating in health promotion activities and recommended health screening. Long-term monitoring for anemia is performed to identify vitamin B deficiency, which may occur when a significant portion of the terminal ileum is removed. This may take several years to develop and can be treated with vitamin B injections. The patient and family are informed of the United Ostomy Association and any local ostomy support groups to provide ongoing support, assistance, and education.
Postoperative Evaluation EXPECTED PATIENT OUTCOMES Expected patient outcomes may include: 1. Maintains skin integrity a. Maintains intact peristomal skin and demonstrates skill in managing drainage system and appliance b. Reports absence of pain or discomfort in peristomal area c. States actions to take if skin excoriation occurs 2. Exhibits increased knowledge about managing urinary function a. Participates in managing urinary system and skin care b. Verbally describes anatomic alteration due to surgery c. Revises daily routine to accommodate urinary drainage management d. Identifies potential problems, reportable signs and symptoms, and subsequent measures to take 3. Exhibits improved self-concept as evidenced by the following: a. Voices acceptance of urinary diversion, stoma, and appliance b. Demonstrates increasingly independent self-care, including hygiene and grooming c. States acceptance of support and assistance from family members, health care providers, and other ostomates 4. Copes with sexuality issues a. Verbalizes concern about possible alterations in sexuality and sexual function b. Reports discussion of sexual concerns with partner and appropriate counselor 5. Demonstrates knowledge needed for self-care a. Performs self-care and proficient management of urinary diversion and appliance b. Asks questions relevant to self-management and prevention of complications c. Identifies signs and symptoms needing care from physician or other health care providers 6. Absence of complications as evidenced by the following: a. Reports absence of pain or tenderness in abdomen b. Has temperature within normal range
Chapter 45 c. Reports no urine leakage from incision or drains d. Has urine output within desired volume limits e. Maintains stoma that is red or pink, moist, and appropriately “budded” f. Has intact and healed stomal border
Other Urinary Tract Disorders NEPHROSCLEROSIS Nephrosclerosis is hardening, or sclerosis, of the arteries of the kidney due to prolonged hypertension. This causes decreased blood flow to the kidney and patchy necrosis of the renal parenchyma. Eventually, fibrosis occurs and glomeruli are destroyed. Nephrosclerosis is a major cause of ESRD (Segura, Campo, Rodicio & Ruilope, 2001).
Pathophysiology There are two forms of nephrosclerosis: malignant (accelerated) and benign. Malignant nephrosclerosis is often associated with malignant hypertension (diastolic blood pressure higher than 130 mm Hg). It usually occurs in young adults, and men are affected twice as often as women. The disease process progresses rapidly. Without dialysis, more than half of patients die from uremia in a few years. Benign nephrosclerosis is usually found in older adults and is often associated with atherosclerosis and hypertension.
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urethral obstruction at the bladder outlet by an enlarged prostate gland. Hydronephrosis can also occur in pregnancy because of the enlarged uterus. High pressure in the bladder during the filling phase, generally 15 cm H2O or higher, has been found to result in hydronephrosis, due to the high pressure radiating to one or both kidneys via the ureter (Ghobish, 2001). Whatever the cause, as the urine accumulates in the renal pelvis, it distends the pelvis and its calyces. In time, atrophy of the kidney results. As one kidney undergoes gradual destruction, the other kidney gradually enlarges (compensatory hypertrophy). Ultimately, renal function is impaired.
Clinical Manifestations The patient may not have symptoms if the onset is gradual. Acute obstruction may produce aching in the flank and back. If infection is present, dysuria, chills, fever, tenderness, and pyuria may occur. Hematuria and pyuria may be present. If both kidneys are affected, signs and symptoms of chronic renal failure may develop.
Medical Management
Symptoms are rare early in the disease, even though the urine usually contains protein and occasional casts. Renal insufficiency and associated signs and symptoms occur late in the disease.
The goals of management are to identify and correct the cause of the obstruction, to treat infection, and to restore and conserve renal function. To relieve the obstruction, the urine may have to be diverted by nephrostomy (see Chap. 44) or another type of diversion. The infection is treated with antibiotic agents because residual urine in the calyces leads to infection and pyelonephritis. The patient is prepared for surgical removal of obstructive lesions (calculus, tumor, obstruction of the ureter). If one kidney is severely damaged and its function is destroyed, nephrectomy (removal of the kidney) may be performed.
Medical Management
URETHRITIS
Treatment of nephrosclerosis is aggressive antihypertensive therapy. In hypertensive nephrosclerosis, therapy containing an ACE inhibitor, alone or in combination with other antihypertensive medications, significantly reduces the incidence of renal events. This effect is independent of blood pressure control (Segura et al., 2001).
Urethritis (inflammation of the urethra) is usually an ascending infection and may be classified as gonococcal or nongonococcal. Both conditions may be present in the same patient. Gonococcal urethritis and nongonococcal urethritis are the most common STDs in men in developed countries (Centers for Disease Control and Prevention, 2001). Gonococcal urethritis is caused by N. gonorrhoeae and is transmitted by sexual contact. In men, inflammation of the urethral meatus or orifice occurs, with burning on urination. A purulent urethral discharge appears 3 to 14 days (or longer) after sexual exposure, although the disease is asymptomatic in up to 10% of men. The infection involves the tissues around the urethra, causing periurethritis, prostatitis, epididymitis, and urethral stricture. Sterility may occur as a result of vasoepididymal obstruction. Gonorrhea in women is frequently not diagnosed and reported because a urethral discharge is not always present and the disease may be asymptomatic. Treatment of gonorrhea is discussed and patient education information is provided in Chapter 70. Nongonococcal urethritis is usually caused by C. trachomatis or Ureaplasma urealyticum. Male patients with symptoms usually complain of mild to severe dysuria and scant to moderate urethral discharge. Nongonococcal urethritis requires prompt treatment with tetracycline or doxycycline. In patients who do not respond to or who are allergic to the tetracyclines, erythromycin may be substituted. Follow-up care is necessary to make certain that a cure is achieved. All sexual partners of patients with
Assessment and Diagnostic Findings
HYDRONEPHROSIS Hydronephrosis is dilation of the renal pelvis and calyces of one or both kidneys due to an obstruction.
Pathophysiology Obstruction to the normal flow of urine causes the urine to back up, resulting in increased pressure in the kidney. If the obstruction is in the urethra or the bladder, the back pressure affects both kidneys, but if the obstruction is in one of the ureters because of a stone or kink, only one kidney is damaged. Partial or intermittent obstruction may be caused by a renal stone that has formed in the renal pelvis but has moved into the ureter and blocked it. The obstruction may be due to a tumor pressing on the ureter or to bands of scar tissue resulting from an abscess or inflammation near the ureter that pinches it. The disorder may be due to an odd angle of the ureter as it leaves the renal pelvis or to an unusual position of the kidney, favoring a ureteral twist or kink. In elderly men, the most common cause is
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nongonococcal urethritis should be examined for STDs and treated.
RENAL ABSCESS Renal abscesses may be localized to the renal cortex (renal carbuncle) or extend into the fatty tissue around the kidney (perinephric abscess). The incidence of renal abscesses ranges from 1 to 10 cases per 10,000 hospital admissions.
Pathophysiology A renal abscess may be caused by an infection of the kidney (pyelonephritis) or may occur as a hematogenous (spread through the bloodstream) infection originating elsewhere in the body. Offending organisms include Staphylococcus and Proteus species and E. coli. Occasionally, infection spreads from adjacent areas, such as with diverticulitis or appendicitis.
Clinical Manifestations The manifestations of a perinephritic abscess often are acute in onset, with chills, fever, leukocytosis, a dull ache or palpable mass in the flank, abdominal pain with guarding, and CVA tenderness on palpation. The patient usually appears seriously ill.
Assessment and Diagnostic Findings The patient with a renal abscess may report a recent history of a cutaneous boil or carbuncle and may complain of malaise, fever, chills, anorexia, weight loss, and a dull pain over the kidney. Leukocytosis and sterile urine (no microorganisms seen because the infection does not extend into the urinary collection system) are present with renal abscesses localized to the renal cortex. The CT examination results are important both in the diagnostic phase to establish the extent of the lesions and in the follow-up phase to assess the effectiveness of treatment (Dalla Palma, PozziMucelli & Ene, 1999).
Management Small localized abscesses are usually cured by intravenous antibiotic medications alone but may require incision and drainage. Perinephritic abscesses require percutaneous drainage of the abscess. Culture and sensitivity tests are performed, and appropriate antibiotic therapy is prescribed. Drains are usually inserted and left in the perinephric space until all significant drainage has ceased. Because the drainage is often profuse, frequent changes of the outer dressings may be necessary. As in treating an abscess in any site, the patient is monitored for sepsis, fluid intake and output, and general response to treatment. Surgery may be indicated for extensive perinephritic abscesses.
TUBERCULOSIS OF THE URINARY TRACT Pathophysiology Tuberculosis of the urinary tract is caused by the organism Mycobacterium tuberculosis and is relatively rare in developed countries. The organism usually travels from the lungs by means of the bloodstream to the kidneys. On arrival in the kidney, the microorganism may lie dormant for years. After the organism reaches the kidney, a low-grade inflammation and the characteristic tubercles are seen.
If the organism continues to multiply, the tubercles enlarge to form cavities, with eventual destruction of parenchymal tissue. The organism spreads down the urinary tract into the bladder and may also infect the prostate, epididymis, and testicles in men.
Clinical Manifestations At first, the signs and symptoms of renal tuberculosis are mild; there is usually a slight afternoon fever, weight loss, night sweats, loss of appetite, and general malaise. Hematuria (microscopic or gross) and pyuria may be present. Pain, dysuria, and urinary frequency, when they occur, are due to bladder involvement. Cavity formations and calcifications may be noted on an intravenous urogram.
Assessment and Diagnostic Findings A search for tuberculosis elsewhere in the body is conducted when tuberculosis of the kidney or urinary tract is found. The patient is asked about possible exposure to tuberculosis. Three or more clean-catch, first-morning urine specimens are obtained for culture for M. tuberculosis. The erythrocyte sedimentation rate is usually elevated and is helpful in monitoring response to treatment. Other diagnostic studies include intravenous urography, biopsy, and urine culture for acid-fast bacilli. Recent studies have shown that the polymerase chain reaction (PCR) provides a much faster diagnosis of urinary M. tuberculosis. It is a rapid, sensitive, and specific diagnostic method and avoids a delay in starting treatment (Hemal, Gupta, Rajeev et al., 2000).
Medical Management The goal of treatment is to eradicate the offending organism. Combinations of ethambutol, isoniazid, and rifampin are used to delay the emergence of resistant organisms. Shorter-course chemotherapy (4 months) has been effective in eradicating the organism and in penetrating renal tissue. Surgical intervention may be necessary to treat obstruction and to remove an extensively diseased kidney. Because renal tuberculosis is a manifestation of a systemic disease, all measures to promote the general health of the patient are taken, including proper nutrition, adequate rest, and good hygiene practices. A scrotal support may be used by male patients with genital swelling.
Nursing Management For the most part, nursing interventions focus on patient education to promote effective self-care at home and to prevent active recurrence or transmission of disease. Instructions are provided about taking prescribed medications properly, recognizing adverse effects, and understanding the importance of completing the course of therapy. Instructions are also given regarding the nature of tuberculosis; its cause, spread, and treatment; and necessary follow-up care. Men are instructed to use condoms during sexual intercourse to prevent spread of the organisms; those with penile or urethral tuberculosis are instructed to abstain from intercourse during treatment. The patient is encouraged to maintain a healthy lifestyle with a well-balanced diet, adequate intake of fluids, and exercise. Follow-up care is essential to reinforce the importance of taking medications exactly as prescribed (many patients do not take
Chapter 45 them correctly). The patient is counseled about the need for follow-up examinations (urine cultures, intravenous urograms), usually for 1 year. Treatment is reinstituted if a relapse occurs and the tubercle bacilli again invade the genitourinary tract. Because ureteral stenosis or bladder contractures may develop during healing, the patient is monitored for these complications.
URETHRAL STRICTURES A urethral stricture is a narrowing of the lumen of the urethra as a result of scar tissue and contraction.
Pathophysiology Common causes of strictures are urethral injury (caused by insertion of surgical instruments during transurethral surgery, indwelling catheters, or cystoscopic procedures), straddle injuries, and injuries associated with automobile crashes, untreated gonorrheal urethritis, and congenital abnormalities.
Assessment and Diagnostic Findings The patient reports that the force and volume of the urinary stream are diminished, and symptoms of urinary infection and retention occur. Stricture causes urine to back up, resulting in cystitis, prostatitis, and pyelonephritis.
Prevention An important element of prevention is to treat all urethral infections promptly. Prolonged urethral catheter drainage should be avoided and the utmost care taken in any type of instrumentation involving the urethra, including catheterization.
Medical Management Treatment may include gradual dilation of the narrowed area (with metal sounds or bougies) or surgery (internal urethrotomy). If the stricture prevents the passage of a catheter, the urologist uses several small filiform bougies in search of the opening. When one bougie passes beyond the stricture into the bladder, it is fixed in place, and urine drains from the bladder. The opening then can be dilated, bypassing a larger sound (a dilating instrument), with the filiform then acting as a guide. After dilation, hot sitz baths and nonopioid analgesic agents are administered to control pain. Antibiotic medications are prescribed for several days after dilation to prevent infection. Surgical excision or urethroplasty may be necessary for severe cases. A suprapubic cystostomy may be necessary in some patients. The postoperative management for cystostomy is described earlier in this chapter. Research studies using the diode laser to treat urethral strictures suggest that it is safe and reliable, especially as the first line of treatment (Kamal, 2001).
RENAL CYSTS Renal cysts are abnormal, fluid-filled sacs that arise from the kidney tissue. They may be genetic in origin, acquired, or associated with a host of unrelated conditions. Cysts of the kidney may be single or multiple (polycystic), involving one or both kidneys. Polycystic disease of the adult is inherited as an autosomal dominant trait and affects men and women equally.
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Autosomal Dominant Polycystic Kidney Disease Autosomal dominant polycystic kidney disease is a common inherited condition, occurring in between 1 in 200 and 1 in 1,000 of the population. After diagnosis, patients are usually treated by nephrologists because of the risk of progression to ESRD. Almost two thirds (64%) of people with adult polycystic kidney disease also develop hematuria. Most episodes are due to UTIs and rupture of renal cysts that relate to the underlying anatomic abnormalities. The symptoms are usually short-lived and resolve with conservative measures such as rest and antibiotic treatment. Renal stone disease is also common, occurring in 20% of patients. Frank hematuria is also a presenting symptom of common, but unrelated, disorders that may occur coincidentally. These patients must be evaluated to rule out a genitourinary cancer because hematuria is also a presenting symptom of urinary tract cancer. Simple noninvasive diagnostic studies such as transabdominal ultrasound and urine cytology may demonstrate additional pathology that needs treatment to reduce further morbidity (Dedi, Bhandari, Turney et al., 2001). Polycystic renal disease is also associated with cystic diseases of other organs (liver, pancreas, spleen) and aneurysms of the cerebral arteries. It has long been recognized that patients on longterm dialysis (both hemodialysis and peritoneal dialysis) develop multiple cysts on their nonfunctioning kidneys. Many of these cysts contain cancer cells.
Acquired Cystic Kidney Disease An acquired form of polycystic disease occurring as a result of ESRD associated with dialysis is called acquired cystic kidney disease. While most of the cysts remain benign, serious complications can develop. Acquired cystic kidney disease has been associated with cyst infection, cyst hemorrhage, retroperitoneal hemorrhage, and spontaneous rupture of the kidney; therefore, it is important for the nurse to be aware of this variation of cystic kidney disease (Dedi, Bhandari, Turney et al., 2001; Headley & Wall, 1999).
Clinical Manifestations The kidney gradually enlarges, with signs and symptoms becoming apparent in the fourth or fifth decade of life. The patient reports abdominal or lumbar pain. Hematuria, hypertension, palpable renal masses, and recurrent UTIs are additional manifestations. Renal insufficiency and failure usually develop in the end stages. Diagnosis of renal cysts is confirmed either by intravenous urography or CT scan.
Management Because there is no specific treatment for polycystic renal disease, patient care focuses on relief of pain, symptoms, and complications. Hypertension and UTIs are treated aggressively. Dialysis (see Chap. 44) is initiated when signs and symptoms of renal insufficiency and failure occur. Genetic counseling is part of management with polycystic kidney disease that is genetic in origin. The patient is advised to avoid sports and occupations that present a risk for trauma to the kidney. Simple cysts of the kidney usually occur unilaterally and differ clinically and pathophysiologically from polycystic kidney disease. In such cases, the cyst may be drained percutaneously.
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CONGENITAL ANOMALIES Congenital anomalies of the kidney are not uncommon. Occasionally, there is fusion of the two kidneys, forming what is called a horseshoe kidney. One kidney may be small and deformed and is often nonfunctioning. The patient may have a double ureter or congenital stricture of the ureter. Treating these anomalies is necessary only if they cause symptoms, but it is essential to determine that the other kidney is present and functioning before surgery is undertaken.
INTERSTITIAL CYSTITIS Interstitial cystitis, a chronic inflammatory condition of the bladder wall, frequently remains undiagnosed. The cause is unknown and no treatment is effective for all patients, although several treatments are available and most patients obtain some relief. More than 700,000 Americans have interstitial cystitis. It can occur at any age and in all ethnic groups and both genders, although 90% of those affected are women. The average age at onset is 40, although one in four people affected is under age 30 at onset of symptoms. Preliminary results of studies of men with nonbacterial prostatitis indicate that many of them may also have interstitial cystitis (Interstitial Cystitis Association, 2001).
Pathophysiology Although no single theory can explain the disorder, several pathophysiologic mechanisms may cause it, including changes in epithelial permeability, pelvic floor dysfunction, mastocytosis, activation of C-fibers, increase of nerve growth factors, and bradykinin. A decrease in the glycosaminoglycan (GAG) layer on the urothelium is thought to be a possible cause (DoggweilerWiygul, Blankenship & MacDiarmid, 2001).
Clinical Manifestations Interstitial cystitis is characterized by severe, irritable voiding symptoms (day and night frequency, nocturia, urgency), pain and discomfort (suprapubic pressure, pain with bladder filling, suprapubic or perineal pain and pressure), and a markedly diminished bladder capacity. Some patients void more than 60 times a day. Sexual intercourse is often painful (Doggweiler-Wiygul et al., 2001). Patients commonly present with multiple health problems that may be difficult to diagnose and may be associated with changes in the immune system. Patients with chronic fatigue syndrome, fibromyalgia, and temporomandibular disorder share many clinical illness features such as myalgia, fatigue, sleep disturbances, and impaired ability to perform activities of daily living as a consequence of these symptoms. Research findings suggest that various other chronic illnesses and pain syndromes may be associated with interstitial cystitis, including irritable bowel syndrome and chronic tension-type headache (Aaron, Burke & Buchwald, 2000).
Assessment and Diagnostic Findings The diagnosis is made by excluding other causes of the symptoms. Diagnosis is complicated because there are no definitive diagnostic criteria. As a result, several years may pass and patients see an average of four or five physicians before the definitive diagnosis is made. The lack of more specific diagnostic criteria does
not mean that interstitial cystitis is psychologically based; rather, it is a physical disorder with psychological consequences. Many patients have difficulty coping with the lack of a diagnosis, the inability of health care professionals to provide an explanation for their symptoms, and the persistence of symptoms.
Medical Management Treatment strategies include use of medications that target pain and discomfort. Other therapies are used with the goal of repairing the bladder wall or their anti-inflammatory effects. PHARMACOLOGIC THERAPY In 1996, the FDA approved the use of a bladder protectant, pentosan polysulfate sodium (Elmiron), which is given orally. Since its introduction, Elmiron has been the most effective agent; it is the only oral agent in its class. Intrabladder instillation of various compounds (eg, silver nitrate, dimethyl sulfoxide, oxychlorosene [Clorpactin]) may provide relief. About 50% of patients respond favorably to intravesicular instillation of dimethyl sulfoxide. Antispasmodic agents, such as oxybutynin (Ditropan), and urinary mucosal anesthetic agents, such as phenazopyridine (Pyridium), may be useful. Intravesicular heparin has some effect in decreasing symptoms in half of patients. Patients must be able to selfcatheterize to instill the heparin on a daily basis initially, then three or four times weekly. Tricyclic antidepressant medications (doxepin and amitriptyline), which have central and peripheral anticholinergic actions, may decrease the excitability of smooth muscle in the bladder and reduce pain and discomfort. OTHER THERAPY Other treatments include transcutaneous electrical nerve stimulation (TENS) and destruction of ulcers with laser photoirradiation. Percutaneous sacral nerve stimulation is a means of neuromodulation to decrease the pelvic area pain and irritable bladder symptoms. Some women with intractable interstitial cystitis respond favorably to percutaneous sacral stimulation, with a significant improvement in pelvic pain, daytime frequency, nocturia, urgency, and average voided volume. Permanent sacral implantation can be an effective treatment modality in refractory interstitial cystitis; further long-term evaluation is required, although initial results are promising (Interstitial Cystitis Association, 2001).
Nursing Management Often, the patient has experienced symptoms for a prolonged time. These symptoms prevent the patient from carrying out normal activities of daily living. The patient has usually been treated by a number of health care providers, often with little relief of symptoms. As a consequence, the patient may feel depressed, anxious, distrustful, and skeptical about proposed treatments.
? 1.
Critical Thinking Exercises
As the head nurse in a nursing home, you are approached by the daughter of one of the patients. She requests that her mother, who can ambulate with assistance, have an indwelling urinary catheter inserted “for convenience sake.” Based on your knowledge regarding the effects of long-term indwelling catheter use, what would be your response?
Chapter 45
2.
Your patient is a 50-year-old woman who has been on hemodialysis for 7 years. On her baseline renal ultrasound, three small cysts were noted. She was recently started on anticoagulation therapy to maintain the patency of her venous access. This morning she presents for dialysis with severe flank pain. Identify possible causes of her pain and laboratory tests that would be indicated. What nursing assessment and interventions should you take at this time? What explanations would you give the patient while awaiting the results of laboratory tests?
3.
Your 60-year-old patient has undergone a cystectomy and continent urinary diversion surgery. Your responsibility is to assist the patient in learning to manage the urinary diversion. Describe the postoperative patient teaching that you will provide to the patient and family. How will you modify the postoperative teaching if the patient and family have limited understanding of English? If the patient is blind?
4.
A 35-year-old woman presents to the urinary clinic with complaints of frequent daytime urination with nearly constant voiding urgency without any incontinence, postcoital suprapubic discomfort, and nocturia (averaging three times a night). A urinalysis is negative for bacteria but reveals microscopic hematuria. A urodynamic study and office cystoscopy are scheduled to assess for interstitial cystitis. Outline the patient teaching you will provide to her about the diagnostic workup and about management of interstitial cystitis.
In such situations, the nurse assesses the patient’s ability to cope with the disorder and provides psychological support. The nurse must convey a sense of acceptance to the patient and acknowledge the severity of the symptoms and their effect on the patient’s lifestyle. The nurse also teaches the patient about diagnostic tests and treatment regimens (Degler, 2000). REFERENCES AND SELECTED READINGS Books American Cancer Society. (2002). Cancer facts and figures. Atlanta, GA: American Cancer Society. Brown, E. A., & Parfrey, P. S. (Eds.) (1999). Complications of long-term dialysis. New York: Oxford University Press, Inc. Danovitch, G. M. (Ed.) (2000). Handbook of kidney transplantation. Philadelphia: Lippincott Williams & Wilkins. Daugirdas, J. T., & Blake, P. G. (Eds.) (2000). Handbook of dialysis. New York: Little Brown & Co. Gutch, C. F., Stoner, M. H., & Corea, A. L. (1999). Review of hemodialysis for nurses and dialysis personnel (6th ed.). St. Louis: Mosby, Inc. Johnson, R. J., & Feehally, J. (2000). Comprehensive clinical nephrology. St. Louis: Mosby-Year Book. Karlowicz, K. (1995). Urologic nursing: Principles and practice. Philadelphia: W. B. Saunders. Metheny, N. (2000). Fluid and electrolyte balance: Nursing considerations (4th ed.). Philadelphia: Lippincott Williams & Wilkins. Parker, J. (1998). Contemporary nephrology nursing. Pitman, NJ: Anthony J. Janetti, Inc. Reilly, N. J. (Ed.) (2001). Urologic nursing: A study guide (2d ed.). Pitman, NJ: Society of Urologic Nurses and Associates, Inc. Schrier, R. W. (Ed.) (2000). Manual of nephrology. Philadelphia: Lippincott Williams & Wilkins. Schwab, S. J. (Ed.) (2000). 2000 yearbook of nephrology, hypertension and mineral metabolism. St. Louis: Mosby-Year Book, Inc.
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Shapiro, R. (2000a). Decision making in nephrology. St. Louis: MosbyYear Book, Inc. Walsh, P., Retik, A., Vaughan, E., & Wein, A. (Eds.) (1997). Campbell’s urology (7th ed.). Philadelphia: W. B. Saunders.
Journals Asterisks indicate nursing research articles. General Bakris, G. L., Williams, M., Dworkin, L., et al. (2000). Special report: Preserving renal function in adults with hypertention and diabetes: A consensus approach. American Journal of Kidney Diseases, 36(3), 646–661. Cely, C. M., & Contreras, G. (2001). Approach to the patient with hypertention, unexplained hypokalemia and metabolic alkalosis. American Journal of Kidney Diseases, 37(3), pE24. Centers for Disease Control and Prevention. (2001). Evaluation of sexually transmitted disease control practices for male patients with urethritis at a large group practice affiliated with a managed care organization, Massachusetts, 1995–1997. MMWR Morbidity & Mortality Weekly Report, 500(22), 460–462 Criner, J. A., Appelt, M., Coker, C., et al. (2002). Rhabdomyolysis: The hidden killer. MedSurg Nursing, 11(3), 138–143, 155. Dalla Palma, L., Pozzi-Mucelli, F., & Ene, V. (1999). Medical treatment of renal and perirenal abscesses: CT evaluation. Clinical Radiology, 54(12), 792–797. Fink, J. C., Blahut, S. A., Reddy, M., & Light, P. D. (2001). Use of erythropoietin before the initiation of dialysis and its impact on mortality. American Journal of Kidney Diseases, 37(2), 348–355. Ghobish, A. G. (2001). Storage detrusor pressure in bilateral hydroureteronephrosis. European Urology, 39(5), 571–574. Hemal, A. K., Gupta, N. P., Rajeev, T. P., et al. (2000). Polymerase chain reaction in clinically suspected genitourinary tuberculosis: Comparison with intravenous urography, bladder biopsy, and urine acid-fast bacilli culture. Urology, 56(4), 570–574. Kamal, B. A. (2001). The use of the diode laser for treating urethral strictures. British Journal of Urology International, 877(9), 831–833. Kang, D. H., Anderson, S., Kim, Y. G., et al. (2001). Impaired angiogenesis in the aging kidney: Vascular endothelial growth factor and thrombospondin-1 in renal disease. American Journal of Kidney Diseases, 37(3), 601–611. Myhre, M. J. (2000). Herbal remedies, nephropathies and renal disease. Nephrology Nursing Journal, 27(5), 473–478. Nzerue, C. M., Hewan-Lowe, K., & Riley, Jr., L. J. (2000). Cocaine and the kidney: A synthesis of pathophysiologic and clinical perspectives. American Journal of Kidney Diseases, 35(5), 783–795. O’Neill, W. C. (2000). Sonographic evaluation of renal failure. American Journal of Kidney Diseases, 35(6), 1021–1038. Scolari, F., Tardanico, R., Zani, R., et al. (2000). Cholesterol crystal embolism: A recognizable cause of renal disease. American Journal of Kidney Diseases, 36(3), 1089–1109. Segura, J., Campo, C., Rodicio, J. L., & Ruilope, L. M. (2001). ACE inhibitors and appearance of renal events in hypertensive nephrosclerosis. Hypertension, 38(3 Pt 2), 645–649. Acute Renal Failure Dillon, J. (1999). Continuous renal replacement therapy or hemodialysis for acute renal failure? International Journal of Artificial Organs, 22(3), 125–127. Dirkes, S. M. (2000). Continuous renal replacement therapy: Dialytic therapy for acute renal failure in intensive care. Nephrology Nursing Journal, 27(6), 581–590. Gambaro, G., Favaro, S., & D’Angelo, A. (2001). Risk for renal failure in nephrolithiasis. American Journal of Kidney Diseases, 37(2), 233–243. Haas, M., Spargo, B. H., Wit, E. C., & Meehan, S. M. (2000). Etiologies and outcome of acute renal insufficiency in older adults: A renal biopsy study of 259 cases. American Journal of Kidney Diseases, 35(3), 433–447. Lewis, J., Salem, M. M., Chertow, G. M., et al. (2000). Atrial natriuretic factor in oliguric acute renal failure. American Journal of Kidney Diseases, 36(4), 767–774.
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Perrone, R. D., Ruthazer, R., & Terrin, N. C. (2001). Survival after end-stage renal disease in autosomal dominant polycystic kidney disease: Contribution of extrarenal complications to mortality. American Journal of Kidney Diseases, 38(4), 777–784. Chronic Renal Failure Barnas, U., Schmidt, A., Seidl, G., et al. (2001). A comparison of quantitative computed tomography and dual X-ray absorptiometry for evaluation of bone mineral density in patients on chronic hemodialysis. American Journal of Kidney Diseases, 37, 1247–1252. Carey, H. B., Chorney, W., Pherson, K., et al. (2001). Continuous peritoneal dialysis and the extended care facility. American Journal of Kidney Diseases, 37(3), 580–587. Fatica, R. A., Port, F. K., & Young, E. W. (2001). Incidence trends and mortality in end-stage renal disease attributed to renovascular disease in the United States. American Journal of Kidney Diseases, 37(6), 1184–1190. Fink, J. C., Burdick, R. A., Kurth, S. J., et al. (1999). Significance of serum creatinine values in new end-stage renal disease. American Journal of Kidney Diseases, 34(4), 694–701. Fored, C. M., Ejerblad, E., Lindblad, P., et al. (2001). Acetaminophen, aspirin, and chronic renal failure. New England Journal of Medicine, 345(25), 1801–1808. Gunal, A. I., Duman, S., Ozkahya, M., et al. (2001). Strict volume control normalizes hypertention in peritoneal dialysis. American Journal of Kidney Diseases, 37(3), 588–593. Headley, C. M., & Wall, B. (1999). Acquired cystic kidney disease in ESRD. Nephrology Nursing Journal, 26(4), 381–388. Hou, S. (1999). Pregnancy in chronic renal insufficiency and end-stage renal disease. American Journal of Kidney Diseases, 33(2), 235–252. Kalo, Z., Jarey, J., & Nagy, J. (2001). Economic evaluation of kidney transplantation versus hemodialysis in patients with end-stage renal disease. Progress in Transplantation, 11(3), 188–193. Kausz, A. T., Khan, S. S., Abichandani, R., et al. (2001). Management of patients with chronic renal insufficiency in the Northeastern United States. Journal of the American Society of Nephrology, 12(7), 1501–1507. McCoy, K. L., Goldstein, D. R., Gahtan, V., et al. (2001). Peripheral vascular disease intervention in patients with end-stage renal disease: Few complications in those treated with peritoneal dialysis. Southern Medical Journal, 94(10), 997–1001. O’Neill, W. C. (2000). Sonographic evaluation of renal failure. American Journal of Kidney Diseases, 35(6), 1021–1038. U.S. Renal Data System (2001). USRDS 2001 Annual Data Report: Atlas of End-Stage Renal Disease in the United States. National Institutes of Health, National Institute of Diabetes and Digestive and Kidney Diseases, Bethesda, MD. U.S. Renal Data System (USRDS) (2001). Special studies: Cardiovascular disease in end-stage renal disease. http://www.usrds.org/cardiovascular/ default.htm Winkelmayer, W. C., Glynn, R. G., Levin, R., et al. (2001). Determinants of delayed nephrologist referral in patients with chronic kidney disease. American Journal of Kidney Diseases, 38(6), 1178–1184. Wood, E. G., Hand, M., Briscoe, D. M., et al. (2001). Risk factors for mortality in infants and young children on dialysis. American Journal of Kidney Diseases, 37(3), 573–579. Disorders of the Kidney Dedi, R., Bhandari, S., Turney, J. H., et al. (2001). Causes of haematuria in adult polycystic kidney disease. British Medical Journal, 323(8), 386–387. Deschenes, G., & Doucet, A. (2000). Collecting duct Na+/K+-ATPase activity is correlated with urinary sodium excretion in rat nephritic syndromes. Journal of the American Society of Nephrology, 11(4), 604–615. Dunn, M. D., Portis, A. J., Elbahnasy, A. M., et al. (2000). Laparoscopic nephrectomy in patients with end-stage renal disease and autosomal dominant polycystic kidney disease. American Journal of Kidney Diseases, 35(4), 720–725. Fogo, A. (2000). Nephrotic syndrome: Molecular and genetic basis. Nephron, 85(1), 8–13.
Grampsas, S. A., Chandhoke, P. S., Fan, J., et al. (2000). Anatomic and metabolic risk factors for nephrolithiasis in patients with autosomal dominant polycystic kidney disease. American Journal of Kidney Diseases, 36(1), 53–57. Mattoo, T. K., & Mahmoud, M. A. (2000). Increased maintenance corticosteroids during upper respiratory infection decrease the risk of relapse in nephrotic syndrome.Nephron, 85(4), 343–345. Moroni, G., Trendelenburg, M., Del Papa, N., et al. (2001). Anti-C1q antibodies may help in diagnosing a renal flare in lupus nephritis. American Journal of Kidney Diseases, 37(3), 490–498. Winkelmayer, W. C., Eigner, M., Berger, O., et al. (2001). Optic neuropathy in uremia: An interdisciplinary emergency. American Journal of Kidney Diseases, 37(3), E23. Genitourinary Trauma Bayerstock, R., Simons, R., & McLoughlin, M. (2001). Severe blunt trauma: A 7-year retrospective review from a provinicial trauma centre. Canadian Journal of Urology, 8(5), 1372–1376. Dreitlein, D. A., Suner, S., & Basler, J. (2001). Genitourinary trauma. Emergency Medicine Clinics of North America, 19(3), 569–590. Jordan, G. H., Jezior, J. R., & Rosenstein, D. I. (2001). Injury to the genitourinary tract and functional reconstruction of the urethra. Current Opinion in Urology, 11(3), 257–261. Mathevet, P., Valencia, P., Cousin, C., et al. (2001). Operative injuries during vaginal hysterectomy. European Journal of Obstetrics Gynecology and Reproductive Biology, 97(1), 71–75. Morey, A. F., Iverson, A. J., Swan, A., et al. (2001). Bladder rupture after blunt trauma: Guidelines for diagnostic imaging. Journal of Trauma, 51(4), 683–686. Perez-Brayfield, M. R., Keane, T. E., Krishnan, A., et al. (2001). Gunshot wounds to the ureter: A 40-year experience at Grady Memorial Hospital. Journal of Urology, 166(1), 119–121. Interstitial Cystitis Aaron, L. A., Burke, M. M., & Buchwald, D. (2000). Overlapping conditions among patients with chronic fatigue syndrome, fibromyalgia, and temporomandibular disorder. Archives of Internal Medicine, 160(2), 121–127. Degler, M. (2000). Understanding interstitial cystitis. Protocol Driven Healthcare, Inc. Available at: http://www.MyBladder.com Doggweiler-Wiygul, R., Blankenship, J., & MacDiarmid, S. A. (2001). Review on chronic pelvic pain from a urological point of view. World Journal of Urology, 19(3), 160–165. Driscoll, A., & Teichman, J. M. H. (2001). How do patients with interstitial cystitis present? Journal of Urology, 166(6), 2118–2120. Erickson, D. R., Morgan, K. C., Ordille, S., et al. (2001). Non-bladder related symptoms in patients with interstitial cystitis. Journal of Urology, 166(2), 557–562. Interstitial Cystitis Association. (2001). Interstitial Cystitis Fact Sheet. Available at: http://www.ichelp.org/whatisic/welcome.html Lutgendorf, S. K., Kreder, K. J., Rothrock, N. E., et al. (2000). Stress and symptomatology in patients with interstitial cystitis: A laboratory stress model. Journal of Urology, 164(4), 1265–1269. Metts, J. F. (2001). Interstitial cystitis: Urgency and frequency syndrome. American Family Physician, 64(7), 1199–1206. Michael, Y. L., Kawachi, I., Stampfer, M. J., et al. (2000). Quality of life among women with interstitial cystitis. Journal of Urology, 164(2), 423–427. Kidney Transplantation Baan, C. C., van Riemsdijk-Van Overbeeke, I. C., Balk, A. H., et al. (2001). Conversion from cyclosporin A to tacrolimus is safe and decreases blood pressure, cholesterol levels and TGF-beta1 type I receptor expression. Clinical Transplantation, 5(4), 276–283. Chan, L., Gaston, R., & Hariharan, S. (2001). Evolution of immunosuppression and continued importance of acute rejection in renal transplantation. American Journal of Kidney Diseases, 38(6 Suppl. 6), 2S–9S. Cohen, D., & Galbraith, C. (2001). General health management and long-term care of the renal transplant recipient. American Journal of Kidney Diseases, 38(6 Suppl. 6), 10S–24S. Gridelli, B., & Remuzzi, G. (2000). Strategies for making more organs available for transplantation. New England Journal of Medicine, 343(6), 404–410.
Chapter 45 Hariharan, S., Johnson, C. P., Bresnahan, B. A., et al. (2000). Improved graft survival after renal transplantation in the United States, 1988 to 1996. New England Journal of Medicine, 342(9), 605–612. *Hathaway, D. K., Wicks, M. N., Cashion, A. K., et al. (2000). Posttransplant improvement in heart rate variability correlates with improved quality of life. Western Journal of Nursing Research, 22, 749–768. Heeger, P. S., & Hricik, D. (2002). Immune monitoring in kidney transplant recipients revisited. Journal of the American Society of Nephrology, 13(1), 288–290. Hjelmesæth, J., Hartmann, A., Kofstad, J., et al. (2001). Tapering off prednisolone and cyclosporin the first year after renal transplantation: the effect on glucose tolerance. Nephrology Dialysis Transplantation, 16(4), 829–835. Hricik, D. E., Halbert, R. J., Barr, M. L., et al. (2001). Life satisfaction in renal transplant recipients: Preliminary results from the Transplant Learning Center. American Journal of Kidney Disease, 38(3), 580–587. Kalo, Z., Jarey, J., & Nagy, J. (2001). Economic evaluation of kidney transplantation verses hemodialysis in patients with end-stage renal disease. Progress in Transplantation, 11(3), 188–193. Kouli, F., Morrell, C. H., Ratner, L. E., & Kraus, E. S. (2001). Impact of donor/recipient traits independent of rejection on long-term renal function. American Journal of Kidney Diseases, 37(2), 356–365. Mange, K. C., Joffe, M. M., & Feldman, H. I. (2001). Effect of the use or nonuse of long-term dialysis on the subsequent survivor of renal transplants from living donors. New England Journal of Medicine, 344(10), 726–731. McLaughlin, K., Manns, B., Culleton, B., et al. (2001). An economic evaluation of early versus late referral of patients with progressive renal insufficiency. American Journal of Kidney Diseases, 38(5), 1122–1128. Najafian, N., Salama, A. D., Fedoseyeva, E. V., et al. (2002). Enzymelinked immunosorbent spot assay analysis of peripheral blood lymphocyte reactivity to donor HLA-DR peptides: Potential novel assay for prediction of outcomes for renal transplant recipients. Journal of the American Society of Nephrology, 13(1), 252–259. Shapiro, R. (2000b). Tacrolimus in renal transplatation. Graft, 3(2), 64–80. Transplant Patient DataSource. United Network for Organ Sharing. http://www.unos.org. Wijdicks, E. F. (2001). Neurotoxicity of immunosuppressive drugs. Liver Transplantation, 7(11), 937–942. Tumors of the Urinary System and Urinary Diversions Abol-Enein, H., & Ghoneim, M. A. (2001). Functional results of orthotopic ileal neobladder with serous-lined extramural ureteral reimplantation: Experience with 450 patients. Journal of Urology, 165(5), 1427–1432. Amling, C. L. (2001). Diagnosis and management of superficial bladder cancer. Current Problems in Cancer, 25(4), 219–278. Baker, C. P. (2001). The WOC nurse in home care. Journal of Wound Ostomy Continence Nursing, 28(6), 270–273. Benson, M., & Olsson, C. (1999). Continent urinary diversion. Urologic Clinics of North America, 26(1), 125–147. Bellmunt, J., & Albiol, S. (2001). New chemotherapy combinations for advanced bladder cancer. Current Opinion in Urology, 11(5), 517–522. Chang, S. S., Baumgartner, R. G., Wells, N., et al. (2002). Causes of increased hospital stay after radical cystectomy in a clinical pathway setting. Journal of Urology, 167(1), 208–211. Chen, G. L., & Bagley, D. H. (2000). Ureteroscopic management of upper tract transitional cell carcinoma in patients with normal contralateral kidneys. Journal of Urology, 164(4), 1173–1176. Colwell, J. C., Goldberg, M., & Cramel, J. (2001). The state of the standard diversion. Journal of Wound Ostomy Continence Nursing, 28(1), 6–17. Deliveliotis, C., Alargoff, E., Skolarikos, A., et al. (2001). Modified ileal neobladder for continent urinary diversion: experience and results. Urology, 58(5), 712–716. *Floruta, C. V. (2001). Dietary choices of people with ostomies. Journal of Wound Ostomy Continence Nursing, 28(1), 28–31.
Management of Patients With Urinary Disorders
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Guy, R. J., Handa, A., Traill, Z., & Mortensen, N. J. (2001). Rectosigmoid carcinoma at previous ureterosigmoidostomy site in a renal transplant recipient: Report of a case. Diseases of the Colon & Rectum, 44(10), 1534–1536. Hara, I., Miyake, H., Hara, S., et al. (2002). Health-related quality of life after radical cystectomy for bladder cancer: a comparison of ileal conduit and orthotopic bladder replacement. British Journal of Urology International, 89, (1), 10–13. Hart, S., Skinner, E. C., Meyerowitz, B. E., et al. (1999). Quality of life after radical cystectomy for bladder cancer in patients with an ileal conduit, cutaneous or urethral Koch pouch. Journal of Urology, 162(1), 77–81. Hisataki, T., Miyao, N., Masumori, N., et al. (2001). Risk factors for multiple intravesical recurrences of superficial bladder cancer. Urology, 58(6), 935–939. Hock, L. M., Lynch, J., & Balaji, K. C. (2002). Increasing incidence of all stages of kidney cancer in the last 2 decades in the United States: An analysis of surveillance, epidemiology and end results program data. Journal of Urology, 167(1), 57–60. Huang, A., & McPherson, G. A. (2000). Colonic carcinoma after ureterosigmoidostomy. Postgraduate Medical Journal, 76(899), 579–581. Huguet-Perez, J., Palou, J., Millan-Rodriguez, F., et al. (2001). Upper tract transitional cell carcinoma following cystectomy for bladder cancer. European Urology, 40(3), 318–323. Hvarness, H., Krarup, T. & Eldrup, L. (2001). Long-term remission of transitional cell carcinoma after Bacillus Calmette-Guerin instillation in the renal pelvis. Journal of Urology, 166(5), 1829. Jabbour, M. E., Desgrandchamps, F., Cazin, S., et al. (2000). Percutaneous management of grade II upper urinary tract transitional cell carcinoma: The long-term outcome. Journal of Urology, 163(4), 1105–1107. Kane, A. M. (2000). Criteria for successful neobladder surgery: Patient selection and surgical construction. Urologic Nursing, 20(3), 182–188. Kirkali, Z., Tuzel, E., & Munga, U. (2002). Recent advances in kidney cancer and metastatic disease. British Journal of Urology International, 88(8), 818–824. Krupski, T., & Theodorescu, D. (2001). Orthotopic neobladder following cystectomy: Indications, management, and outcomes. Journal of Wound Ostomy Continence Nursing, 28(1), 37–46. Matthews, S. D. & Courts, N. F. (2001). Orthotopic neobladder surgery. American Journal of Nursing, 101(7), 24AA–24GG. Nonomura, N., Ono, Y., Nozawa, M., et al. (2000). Bacillus CalmetteGuerin perfusion therapy for the treatment of transitional cell carcinoma in situ of the upper urinary tract. European Urology, 38(6), 701–705. Okubo, K., Ichioka, K., Matsuta, T. N., et al. (2001). Intrarenal Bacillus Calmette-Guerin therapy for carcinoma in situ of the upper urinary tract: Long-term follow-up and natural course in cases of failure. British Journal of Urology International, 88(4), 343–347. O’Shea, H. S. (2001). Teaching the adult ostomy patient. Journal of Wound Ostomy Continence Nursing, 28(1), 47–54. Pizza, G., De Vinci, C., LoConte, G., et al. (2001). Immunotherapy of metastatic kidney cancer. International Journal of Cancer, 94(1), 109–120. Saad, A., Hanbury, D. C., McNicholas, T. A., et al. (2001). The early detection and diagnosis of bladder cancer: A critical review of the options. European Urology, 39(6), 619–633. Shalhav, A. L., Dunn, M. D., Portis, A. J., et al. (2000). Laparoscopic nephroureterectomy for upper tract transitional cell cancer: The Washington University experience. Journal of Urology, 163(4), 1100–1104. Uzzo, R. L., & Novick, A. C. (2001). Nephron-sparing surgery for renal tumors: Indications, techniques and outcomes. Journal of Urology, 166(1), 6–18. Yachia, D., & Erlich, N. (2001). The Hadera continent reservoir: A new appendico-umbilical continent stoma mechanism for urinary diversion. Journal of Urology, 165(5), 1423–1426.
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Unit 9
RENAL AND URINARY TRACT FUNCTION
Zietman, A. L., Grocela, J., Zehr, E., et al. (2001). Selective bladder conservation using transurethral resection, chemotherapy, and radiation: Management and consequences of TA, T1, and TIS recurrence within the retained bladder. Urology, 58(3), 380–385. Zietman, A. L., Shipley, W. U., & Kaufman, D. S. (2000). Organconserving approaches to muscle-invasive bladder cancer: Future alternatives to radical cystectomy. Annals of Medicine, 32(1), 34–42. Zinman, L. (1999). Changing concepts in orthotopic urinary diversion. Journal of Urology, 161(6), 1807–1808. Urinary Calculi Assimos, D. G. (2001). Anatrophic nephrolithotomy. Urology, 57(1), 161–165. Bihl, G., & Meyers, A. (2001). Recurrent renal stone disease: Advances in pathogenesis and clinical management. Lancet, 358(9282), 651–656. DeLeskey, K. L., & Massi-Ventura, G. (2000). Management of the extracorporeal shock wave lithotripsy patient. Journal of Perianesthesia Nursing, 15(2), 94–101. Gambaro, G., Favaro, S., & D’Angelo, A. (2001). Risk for renal failure in nephrolithiasis. American Journal of Kidney Diseases, 37(2), 233–243. Joshi, H. B., Kumar, P. V., & Timoney, A. G. (2001). Citric acid (solution R) irrigation in the treatment of refractory infection (struvite) stone disease: Is it useful? European Urology, 39(5), 586–590. Liou, L. S., & Streem, S. B. (2001). Long-term renal functional effects of shock wave lithotripsy, percutaneous nephrolithotomy and combination therapy: A comparative study of patients with solitary kidney. Journal of Urology, 166(1), 36–37. Maheshwari, P. N., Oswal, A. T., & Bansal, M. (1999). Percutaneous cystolithotomy for vesical calculi: A better approach. Technical Urology, 5(1), 40–42. Monga, M., & Oglevie, S. (2000). Minipercutaneous nephrolithotomy. Journal of Endourology, 14(5), 419–421. Ryan, C., Hedgepeth, R. C., Yang, L., et al. (2001). Expression of proteins that inhibit calcium oxalate crystallization in vitro in the urine of normal and stone-forming individuals. American Journal of Kidney Diseases, 37(1), 104–112. Streem, S. B. (2000). Percutaneous endopyelotomy. Urology Clinics of North America, 27(4), 685–693. Tawfiek, E., & Bagley, D. (1999). Management of upper urinary tract calculi with ureteroscopic techniques. Urology, 53(1), 25–31. Tombolini, P., Ruoppolo, M., Bellorofonte, C., et al. (2000). Lithotripsy in the treatment of urinary lithiasis. Journal of Nephrology, 13(suppl 3), S71–82. Trinchieri, A., Zanetti, G., Curro, A., & Lizzano, R. (2001). Effect of potential renal acid load of foods on calcium metabolism of renal calcium stone formers. European Urology, 39(suppl 2), 33–37. Williams, C. P., Child, D. F., Hudson, P. R., et al. (2001). Why oral calcium supplements may reduce renal stone disease: Report of a clinical pilot study. Journal of Clinical Pathology, 54(1), 54–62. Urinary Tract Infections Bonadio, M., Meini, M., Spitaleri, P., & Gigli, C. (2001). Current microbiological and clinical aspects of urinary tract infections. European Urology, 40(4), 439–445. Bradley, S. F. (2002). Staphylococcus aureus infections and antibiotic resistance in older adults. Clinical Infectious Disease, 34(2), 211–216. Foxman, B. (2002). Epidemiology of urinary tract infections: Incidence, morbidity, and economic costs. American Journal of Medicine, 113 (Suppl. 1A), 5S–13S. Gomolin, I. H., & McCue, J. D. (2000). Urinary tract infection in the elderly patient. Infections in Urology, 13(5A), s7–s13. Gupta, K., Hooton, T. M., & Stamm, W. E. (2001). Increasing antimicrobial resistance and the management of uncomplicated community-acquired urinary tract infections. Annals of Internal Medicine, 135(1), 41–50. Hooton, T. M., Scholes, D., Stapleton, A. E., et al. (2000). A prospective study of asymptomatic bacteriuria in sexually active young women. New England Journal of Medicine, 343(14), 992–997.
Kontiokari, T., Sundqvist, K., Nuutinen, M., et al. (2001). Randomised trial of cranberry-lingonberry juice and Lactobacillus GG drink for the prevention of urinary tract infections in women. British Medical Journal, 322(7302), 1571. Lawrenson, R. A., & Logie, J. W. (2001). Antibiotic failure in the treatment of urinary tract infections in young women. Journal of Antimicrobial Chemotherapy, 48(6), 895–901. Sabbuba, N., Hughes, G., & Stickler, D. J. (2002). The migration of Proteus mirabilis and other urinary tract pathogens over Foley catheters. British Journal of Urology International, 89(1), 55–60. Stamm, W. E. (2001). An epidemic of urinary tract infections? New England Journal of Medicine, 345(14), 1055–1057. Raz, R. (2001). Postmenopausal women with recurrent UTI. International Journal of Antimicrobial Agents, 17(4), 269–271. Raz, R., Gennesin, Y., Wasser, J., et al. (2000). Recurrent urinary tract infections in postmenopausal women. Clinical Infectious Disease, 30(1), 152–156. Ronald, A. R., Nicolle, L. E., Stamm, E., et al. (2001). Urinary tract infection in adults: Research priorities and strategies. International Journal of Antimicrobial Agents, 17(4), 343–348. Talan, D. A., Stamm, W. E., & Hooton, T. M. (2000). Comparison of ciprofloxan (7 days) and trimethoprim-sulfamethoxazole (14 days) for acute uncomplicated pyelonephritis in women: A randomized trial. Journal of the American Medical Association, 283(12), 1583–1590. Thees, K., & Dreblow, L. (1999). Trial of voiding: What’s the verdict? Urologic Nursing, 19(1), 20–22. Warren, J. W., Abrutyn, E., Hebel, R. J., et al. (1999). Guidelines for antimicrobial treatment of uncomplicated acute bacterial cystitis and acute pyelonephritis in women. Clinical Infectious Diseases, 29(4), 745–758. Zandi-Nejad, K., & Brown, P. D. (2001). Diagnostic investigation of pyelonephritis. Current Infectious Disease Reports, 3(6), 529–533.
RESOURCES AND WEBSITES American Association of Kidney Patients, 3505 E. Frontage Rd., Suite 315, Tampa, FL 33607; (800) 749-2257; http://www.aakp.org. American Association of Nephrology Nurses, North Woodbury Road, Box 56, Pitman NJ 08071; (609) 589-2187; http://www.annanurse. com. American Cancer Society, 1599 Clifton Rd. NE, Atlanta, GA 30329; (800) ACS-2345; http://www.cancer.org. American Kidney Fund, 6110 Executive Blvd., Suite 1010, Rockville, MD 20852; (800) 638-8299; http://www.arbon.com/kidney. Interstitial Cystitis Association, P.O. Box 1553, Madison Square Garden Station, New York, NY 10159; (212) 979-6057; http://www. ichelp.com. National Association for Patients on Hemodialysis and Transplantation, 211 East 43rd Street, Suite 301, New York, NY 10017; (212) 8674486 National Institute of Diabetes & Digestive and Kidney Diseases (NIDDK), National Institutes of Health, Building 31, Bethesda, MD 20892; http://www.niddk.nih.gov/index.htm. National Kidney Foundation, 30 East 33rd St., New York, NY 10016; (212) 889-2210; http:// www.kidney.org. National Kidney and Urologic Diseases Information Clearinghouse, Box NKUDIC, 3 Information Way, Bethesda, MD, 20892; (800) 891-5390; (301) 654-4415; http://www.niddk.nih.gov/health/ kidney/nkudic.htm. United Ostomy Association, 36 Executive Park, Suite 120, Irvine, CA 92714-6744; (800) 826-0826; http://www.uoa.org. Wound, Ostomy and Continent Nurses Society (WOCN), 2755 Bristol Street, Suite 110, Costa Mesa, CA 92626; (714) 476-0268; http://www.wocn.org.
Chapter
46 ●
Assessment and Management of Female Physiologic Processes
LEARNING OBJECTIVES
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On completion of this chapter, the learner will be able to: 1. Describe female reproductive function. 2. Describe approaches to effective sexual assessment. 3. Describe indicators of domestic violence and abuse of women and 4. 5. 6. 7. 8. 9. 10. 11.
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methods of identifying and treating women who are survivors of abuse. Identify the diagnostic examinations and tests used to determine alteration in female reproductive function and describe the nurse’s role before, during, and after these examinations and procedures. Identify factors that cause disturbances of menstruation and related nursing implications. Describe nursing care for patients with premenstrual syndrome. Develop a teaching plan for women experiencing menopause. Describe methods of contraception and implications for health care and education. Describe the nursing management of the patient having an abortion. Describe the causes and management of infertility. Use the nursing process to plan for the care of patients with ectopic pregnancies.
W
Chapter 46
Assessment and Management of Female Physiologic Processes
omen’s health is a unique specialty of health care. In addition to understanding normal female anatomy and physiology, the nurse needs to understand the physical, developmental, psychological, and social-cultural influences on women’s health and use of health care. Health assessment, maintenance, and promotion across the life span must address growth and development, sexuality, contraception, preconception care, conception, prenatal care, effects of pregnancy on health, aging, perimenopause, menopause, and disorders that affect women. Further, the effects of disability on women’s access to health care and the effect of disabilities and chronic illness on their health status must also be considered. Because women use the health care system more often than men and make up the majority of health care workers, addressing women’s health needs and concerns will improve quality and access for all people.
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and have extended the period of possible childbearing for couples well beyond their 40s. As women exercise greater control over their health care options, nurses are becoming more knowledgeable about preventive care for women, particularly with regard to their unique needs. The nurse encourages women to determine their own health goals and behaviors, teaches about health and illness, offers interventional strategies, and provides support, counseling, and ongoing monitoring. Areas of special interest in health promotion include the following:
• Personal hygiene • Strategies for detecting and preventing disease, especially •
Role of Nurses in Women’s Health
•
As their presence in the labor market has increased, women have faced major changes in their roles, lifestyles, and family patterns. Moreover, they have encountered environmental hazards and stress, prompting them to focus greater attention on health and health-promoting practices. As a result, some women are taking a greater interest in and responsibility for their own health care. Many others do not have the time, finances, or other resources to do so. Other changes over the years have included delaying pregnancy and childbearing until well after a career is established. Various methods of contraception have made this option possible. Advances in the treatment of infertility have enabled many women previously unable to have children to become pregnant
• • •
sexually transmitted diseases (STDs), including human immunodeficiency virus (HIV) infection Issues related to sexuality and sexual function, such as contraception; preconceptional, prenatal, and postnatal care; sexual satisfaction; and menopause Diet, exercise, and other health-promoting practices that maintain and enhance health Avoidance of stressful and abusive situations that are detrimental to health and well-being Maintaining a normal weight for height and avoiding substance abuse and smoking Avoidance of unhealthy lifestyle and risk behaviors
Nurses who promote healthy ways of living also need to model that lifestyle for their patients. An important role of the nurse is promoting positive practices and behaviors related to the reproductive and sexual health of each patient, including the following:
• Providing information about scheduling regular examinations to promote health, detect health problems at an early
Glossary adnexa: the fallopian tubes and ovaries amenorrhea: absence of menstrual flow androgens: hormones produced by the ovaries and adrenals that affect many aspects of female health, including follicle development, libido, oiliness of hair and skin, and hair growth cervix: bottom (inferior) part of the uterus that is located in the vagina chandelier sign: pain on gentle movement of the cervix; associated with pelvic infection corpus luteum: site of a follicle that changes after ovulation to produce progesterone cystocele: weakness of the anterior vaginal wall that allows the bladder to protrude into the vagina dysmenorrhea: painful menstruation dyspareunia: difficult or painful sexual intercourse endometriosis: condition in which endometrial tissue implants in other areas of the pelvis; may produce dysmenorrhea or infertility endometrium: mucous membrane lining the uterus estrogen: hormone that develops and maintains the female reproductive system follicle-stimulating hormone (FSH): hormone released by the pituitary gland
to stimulate estrogen production and ovulation fornix: upper part of the vagina fundus: body of the uterus graafian follicle: cystic structure that develops on the ovary as ovulation begins hymen: tissue that covers the vaginal opening partially or completely before vaginal penetration hysteroscopy: a procedure performed using a long telescope-like instrument inserted through the cervix to diagnose uterine problems introitus: opening to the vagina on the perineum luteal phase: stage in the menstrual cycle in which the endometrium becomes thicker and more vascular luteinizing hormone (LH): hormone released by the pituitary gland that stimulates progesterone production menarche: beginning of menstrual function menopause: permanent cessation of menstruation resulting from the loss of ovarian follicular activity menstruation: sloughing and discharge of the lining of the uterus if conception does not take place
osteoporosis: a disorder in which bones lose density and become porous and fragile ovaries: almond-shaped reproductive organs that produce eggs at ovulation and play a major role in hormone production ovulation: discharge of a mature ovum from the ovary perimenopause: the period immediately prior to menopause and the first year after menopause polyp (cervical or endometrial): growth of tissue on the cervix or endometrial lining; usually benign progesterone: hormone produced by the corpus luteum proliferative phase: stage in the menstrual cycle before ovulation when the endometrium proliferates rectocele: weakness of the posterior vaginal wall that allows the rectal cavity to protrude into the submucosa of the vagina secretory phase: stage of the menstrual cycle in which the endometrium becomes thickened, more vascular, and edematous uterine prolapse: relaxation of pelvic tone that allows the cervix and uterus to descend into the lower vagina
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•
• •
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stage, assess problems related to gynecologic and reproductive function, and discuss questions or concerns related to sexual function and sexuality Providing an open, nonjudgmental environment; this is crucial if the patient is to feel comfortable discussing personal issues. The nurse must convey understanding and sensitivity when discussing these issues and must assess their effects on the patient and the patient’s partner. Recognizing signs and symptoms of abuse and screening all patients in a private and safe environment Recognizing cultural differences and beliefs and respecting sexual orientation and concerns related to both
Anatomic and Physiologic Overview ANATOMY OF THE FEMALE REPRODUCTIVE SYSTEM The female reproductive system consists of external and internal structures. Other anatomic structures that affect the female reproductive system include the hypothalamus and pituitary gland of the endocrine system.
External Genitalia The external genitalia (the vulva) include two thick folds of tissue called the labia majora and two smaller lips of delicate tissue called the labia minora, which lie within the labia majora. The upper portions of the labia minora unite, forming a partial covering for the clitoris, a highly sensitive organ composed of erectile tissue. Between the labia minora, below and posterior to the clitoris, is the urinary meatus. This is the external opening of the female urethra and is about 3 cm (1.5 inches) long. Below this orifice is a larger opening, the vaginal orifice or introitus (Fig. 46-1). On each side of the vaginal orifice is a vestibular (Bartholin’s) gland, a bean-sized
structure that empties its mucous secretion through a small duct. The opening of the duct lies within the labia minora, external to the hymen. The area between the vagina and rectum is called the perineum.
Internal Reproductive Structures The internal structures consist of the vagina, uterus, ovaries, and fallopian or uterine tubes (Fig. 46-2). VAGINA The vagina, a canal lined with mucous membrane, is 7.5 to 10 cm (3 to 4 inches) long and extends upward and backward from the vulva to the cervix. Anterior to it are the bladder and the urethra, and posterior to it lies the rectum. The anterior and posterior walls of the vagina normally touch each other. The upper part of the vagina, the fornix, surrounds the cervix (the inferior part of the uterus). UTERUS The uterus, a pear-shaped muscular organ, is about 7.5 cm (3 inches) long and 5 cm (2 inches) wide at its upper part. Its walls are about 1.25 cm (0.5 inch) thick. The size of the uterus varies, depending on parity (number of viable births) and uterine abnormalities (eg, fibroids, which are a type of tumor that may distort the uterus). A nulliparous woman (one who has not completed a pregnancy to the stage of fetal viability) usually has a smaller uterus than a multiparous woman (one who has completed two or more pregnancies to the stage of fetal viability). The uterus lies posterior to the bladder and is held in position by several ligaments. The round ligaments extend anteriorly and laterally to the internal inguinal ring and down the inguinal canal, where they blend with the tissues of the labia majora. The broad ligaments are folds of peritoneum extending from the lateral pelvic walls and enveloping the fallopian tubes. The uterosacral ligaments extend posteriorly to the sacrum. The uterus has two parts: the cervix, which projects into the vagina, and a larger upper part, the fundus or body, which is covered posteriorly and partly anteriorly by peritoneum. The triangular inner portion of the fundus narrows to a small canal in the cervix that has constrictions at each end, referred to as the external os and internal os. The upper lateral parts of the uterus are called the cornua. From here, the oviducts or fallopian (or uterine) tubes extend outward, and their lumina are internally continuous with the uterine cavity. OVARIES The ovaries lie behind the broad ligaments, behind and below the fallopian tubes. They are oval bodies about 3 cm (1.2 inches) long. At birth, they contain thousands of tiny egg cells, or ova. The ovaries and the fallopian tubes together are referred to as the adnexa.
FUNCTION OF THE FEMALE REPRODUCTIVE SYSTEM Ovulation
FIGURE 46-1
External female genitalia.
At puberty (usually between ages 12 and 14, but earlier for some; 10 or 11 years of age is not uncommon), the ova begin to mature. During a period known as the follicular phase, an ovum enlarges as a type of cyst called a graafian follicle until it reaches the sur-
Chapter 46
Assessment and Management of Female Physiologic Processes
Ovary
Ovarian ligament
Fundus of uterus
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Fallopian tube: Fimbria Infundibulum Ampulla Isthmus Interstitial portion
Uterus: Corpus Isthmus Vagina
FIGURE 46-2
Cervix: Internal os Cervical canal External os
Broad ligament Round ligament
Internal female reproductive structures.
face of the ovary, where transport occurs. The ovum (or oocyte) is discharged into the peritoneal cavity. This periodic discharge of matured ovum is referred to as ovulation. The ovum usually finds its way into the fallopian tube, where it is carried to the uterus. If it meets a spermatozoon, the male reproductive cell, a union occurs and conception takes place. After the discharge of the ovum, the cells of the graafian follicle undergo a rapid change. Gradually, they become yellow (corpus luteum) and produce progesterone, a hormone that prepares the uterus for receiving the fertilized ovum. Ovulation usually occurs 2 weeks prior to the next menstrual period.
The Menstrual Cycle The menstrual cycle is a complex process involving the reproductive and endocrine systems. The ovaries produce steroid hormones, predominantly estrogens and progesterone. Several different estrogens are produced by the ovarian follicle, which consists of the developing ovum and its surrounding cells. The most potent of the ovarian estrogens is estradiol. Estrogens are responsible for developing and maintaining the female reproductive organs and the secondary sex characteristics associated with the adult female. Estrogens play an important role in breast development and in monthly cyclic changes in the uterus. Progesterone is also important in regulating the changes that occur in the uterus during the menstrual cycle. It is secreted by the corpus luteum, which is the ovarian follicle after the ovum has been released. Progesterone is the most important hormone for conditioning the endometrium (the mucous membrane lining the uterus) in preparation for implantation of a fertilized ovum. If pregnancy occurs, the progesterone secretion becomes largely a function of the placenta and is essential for maintaining a normal pregnancy. In addition, progesterone, working with estrogen, prepares the breast for producing and secreting milk. Androgens are also produced by the ovaries, but only in small amounts. These
hormones are involved in the early development of the follicle and also affect the female libido. Two gonadotropic hormones are released by the pituitary gland: FSH and LH. Follicle-stimulating hormone (FSH) is primarily responsible for stimulating the ovaries to secrete estrogen. Luteinizing hormone (LH) is primarily responsible for stimulating progesterone production. Feedback mechanisms, in part, regulate FSH and LH secretion. For example, elevated estrogen levels in the blood inhibit FSH secretion but promote LH secretion, whereas elevated progesterone levels inhibit LH secretion. In addition, gonadotropin-releasing hormone (GnRH) from the hypothalamus affects the rate of FSH and LH release. The secretion of ovarian hormones follows a cyclic pattern that results in changes in the uterine endometrium and in menstruation (Fig. 46-3; Table 46-1). This cycle is typically 28 days in length, but there are many normal variations (21 to 42 days). In the proliferative phase at the beginning of the cycle (just after menstruation), FSH output increases, stimulating estrogen secretion. This causes the endometrium to thicken and become more vascular. In the secretory phase near the middle portion of the cycle (day 14 in a 28-day cycle), LH output increases, stimulating ovulation. Under the combined stimulus of estrogen and progesterone, the endometrium reaches the peak of its thickening and vascularization. The luteal phase begins after ovulation and is characterized by the secretion of progesterone from the corpus luteum. If the ovum is fertilized, estrogen and progesterone levels remain high and the complex hormonal changes of pregnancy follow. If the ovum has not been fertilized, FSH and LH output diminishes, estrogen and progesterone secretion falls, the ovum disintegrates, and the endometrium, which has become thick and congested, becomes hemorrhagic. The product consisting of old blood, mucus, and endometrial tissue is discharged through the cervix and into the vagina. After the menstrual flow stops, the cycle begins again; the endometrium proliferates and thickens from estrogenic stimulation, and ovulation recurs.
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Physiology/Pathophysiology
part of aging and maturation. Menstruation ceases, and because the ovaries are no longer active, the reproductive organs become smaller. No more ova mature; therefore, no ovarian hormones are produced. (An artificial menopause may occur earlier if the ovaries are surgically removed or are destroyed by radiation or chemotherapy.) Besides changes in the reproductive system that reduce estrogen levels, multifaceted changes occur throughout the woman’s body. These changes include neuroendocrinologic, biochemical, and metabolic alterations related to normal maturation or aging (Table 46-2).
Assessment
Mature corpus luteum
Early corpus luteum
Endometrial changes during menstrual cycle
Ovulation
Mature follicle
Degenerating corpus luteum Growing follicle Primary follicle
Day 25 26 27 28 1 2 3 4 5 6 7 8 9 10 11 12 13
Menstruation
Ovulation
Menstrual cycle
FIGURE 46-3
15 16 17 18 19 20 21 22 23 24 25
Times approximate
One menstrual cycle and the corresponding changes in the
endometrium.
Menopausal Period The menopausal period marks the end of a woman’s reproductive capacity. It usually occurs between the ages of 45 and 52 years but may occur as early as age 42 or as late as age 55; the median age is 51. Menopause is not a pathologic phenomenon but a normal
The nurse who is obtaining information from the patient for the health history and performing physical assessment is in an ideal position to discuss the woman’s general health issues, health promotion, and health-related concerns. Topics that are relevant would include fitness, nutrition, cardiovascular risks, health screening, sexuality, abuse, health risk behaviors, and immunizations. Recommendations for health screening are summarized in Chart 46-1.
HEALTH HISTORY AND CLINICAL MANIFESTATIONS In addition to obtaining a general health history, the nurse asks about past illnesses and experiences that are specific to women’s health. Data should be collected about the following: • Menstrual history (including menarche, length of cycles, length and amount of flow, presence of cramps or pain, bleeding between periods or after intercourse, bleeding after menopause) • History of pregnancies (number of pregnancies, outcomes of pregnancies) • History of exposure to medications (diethylstilbestrol [DES], immunosuppressive agents, others) • Pain with menses (dysmenorrhea), pain with intercourse (dyspareunia), pelvic pain • History of vaginal discharge and odor or itching • History of problems with urinary function (ie, frequency or urgency); may be related to STDs or pregnancy • History of problems with bowel or bladder control • Sexual history • History of sexual abuse or physical abuse • History of surgery or other procedures on reproductive tract structures (including female genital mutilation or female circumcision) • History of chronic illness or disability that may affect health status, reproductive health, need for health screening, or access to health care • History of genetic disorder In collecting data related to reproductive health, the nurse is in a unique position to teach patients about normal physiologic processes, such as menstruation and menopause, and to assess possible abnormalities. Many problems experienced by young or middle-aged women can be corrected easily. If allowed to go untreated, however, they may result in anxiety and health problems. Issues related to sexuality and sexual function are typically brought more often to the attention of the gynecologic or women’s health care provider than other health care providers; any nurse, however, should consider these issues to be part of routine health assessment.
Chapter 46
Table 46-1
1
2
3
FOLLICULAR 4
5
6
Ovary Degenerating corpus luteum; beginning follicular development Estrogen Production Low Progesterone Production None FSH Production Increasing LH Production Low Endometrium Degeneration and shedding of superficial layer. Coiled arteries dilate, then constrict again.
Table 46-2
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• Hormonal Changes During the Menstrual Cycle
(TIMES APPROXIMATE) PHASE MENSTRUAL Days
Assessment and Management of Female Physiologic Processes
7
8
9 10
OVULATION
LUTEAL
PREMENSTRUAL
11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28
1
2
Growth and maturation of follicle
Ovulation
Active corpus luteum
Degenerating corpus luteum
Increasing
High
Decreasing
Low
Low
Declining, then a secondary rise Increasing
High, then declining
Low
Low
Increasing
Low, then increasing
High
High
Decreasing
Reorganization and proliferation of superficial layer
Continued growth
Active secretion and glandular dilation; highly vascular; edematous
Vasoconstriction of coiled arteries; beginning degeneration
Decreasing
• Age-Related Changes in Female Reproductive System
Cessation of ovarian function and decreased estrogen production
PHYSIOLOGIC CHANGES
SIGNS AND SYMPTOMS
Decreased ovulation
Decreased/loss of ability to conceive; increased infertility
Onset of menopause
Irregular menses with eventual cessation of menses Hot flashes or flushing; night sweats, sleep disturbances; mood swings; fatigue Bone loss and increased risk for osteoporosis and osteoporotic fractures; loss of height Dyspareunia, resulting in lack of interest in sex Increased risk for urinary tract infection Increased incidence of bacterial infections (atrophic vaginitis) with discharge, itching, and vulvar burning
Vasomotor instability and hormonal fluctuations Decreased bone formation
Decreased vaginal lubrication Thinning of urinary and genital tracts Increased pH of vagina
Relaxing of pelvic musculature
Thinning of pubic hair and shrinking of labia Prolapse of uterus, cystocele, rectocele
Dyspareunia, incontinence, feelings of perineal pressure
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Chart 46-1
REPRODUCTIVE FUNCTION
Summary of Health Screening and Counseling Issues for Women
Ages 19–39 Sexuality and Reproductive Issues Annual pelvic examination Annual clinical breast exam Contraceptive options High-risk sexual behaviors Health and Risk Behaviors Hygiene Injury prevention Nutrition Exercise patterns Risk for domestic abuse Use of tobacco, drugs, and alcohol Life stresses Immunizations Diagnostic Testing* Pap smear STD screening as indicated Ages 40–64 Sexuality and Reproductive Issues Annual pelvic examination Annual clinical breast exam Contraceptive options High-risk sexual behaviors Menopausal concerns Health and Risk Behaviors Hygiene Bone loss and injury prevention Nutrition Exercise patterns Risk for domestic abuse Use of tobacco, drugs, and alcohol
Life stresses Immunizations Diagnostic Testing* Pap smear Mammography Cholesterol and lipid profile Colorectal cancer screening Bone mineral density testing Thyroid-stimulating hormone testing Hearing and eye examinations Ages 65 and Over Sexuality and Reproductive Issues Annual pelvic examination Annual clinical breast exam High-risk sexual behaviors Health and Risk Behaviors Hygiene Injury prevention Nutrition Exercise patterns Risk for domestic abuse Use of tobacco, drugs, and alcohol Life stresses Immunizations Diagnostic Testing* Pap smear Mammography Cholesterol and lipid profile Colorectal cancer screening Bone mineral density testing Thyroid-stimulating hormone testing Hearing and eye examinations
*Each individual’s risks (family history, personal history) influence the need for specific assessments and their frequency.
Sexual History A sexual assessment includes both subjective and objective data. Health and sexual histories, physical examination findings, and laboratory results are all part of the database. The purpose of a sexual history is to obtain information that provides a picture of the woman’s sexuality and sexual practices and promotes sexual health. The sexual history may enable the patient to discuss sexual matters openly and to discuss sexual concerns with an informed health professional. This information can be obtained with the health history after the gynecologic-obstetric or genitourinary history is completed. By incorporating the sexual history into the general health history, the nurse can move from areas of lesser sensitivity to areas of greater sensitivity after establishing initial rapport. Taking the sexual history becomes a dynamic process reflecting an exchange of information between the patient and the nurse and provides the opportunity to clarify myths and explore areas of concern that the patient may not have felt comfortable discussing in the past. In obtaining a sexual history, the nurse must not assume the patient’s sexual preference until clarified. When asking about sexual health, the nurse also cannot assume that the patient is married or unmarried. Asking a woman to label herself as single, married, widowed, or divorced may be seen as an inappropriate inquiry by the patient. Asking about a partner or about current meaningful relationships may be a less offensive way to initiate a sexual history.
The PLISSIT (Permission, Limited Information, Specific Suggestions, Intensive Therapy) model of sexual assessment and intervention may be used to provide a framework for nursing interventions (Annon, 1976). The assessment begins by introducing the topic and asking the woman for permission to discuss issues of sexual functioning with her. The nurse can begin by explaining the purpose of obtaining a sexual history (eg, “I ask all my patients about their sexual health. May I ask you some questions about this?”). History taking continues by inquiring about present sexual activity and sexual orientation (eg, “Are you currently having sex with a man, a woman, or both?”). Inquiries about possible sexual dysfunction may include, “Are you having any problems related to your current sexual activity?” Such problems may be related to medication, life changes, disability, or the onset of physical or emotional illness. Patients can be asked about their thoughts on what is causing the current problem. Limited information about sexual function may be provided to the patient. As the discussion progresses, the nurse may offer specific suggestions for interventions. For some women, a professional who specializes in sex therapy may provide more intensive therapy as needed. By initiating an assessment about sexual concerns, the nurse communicates to the patient that issues about changes in sexual functioning are valid health topics for discussion and provides a safe environment for discussing these sensitive topics.
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GENETICS IN NURSING PRACTICE—Reproductive Disorders Various reproductive disorders are influenced by genetic factors. Some examples are: • Hereditary breast or ovarian cancer syndromes • Hereditary nonpolyposis colon cancer syndrome (risk for uterine cancer) • Müllerian aplasia • 21-Hydroxylase deficiency (female masculinization) • Turner syndrome (45,XO) • Klinefelter syndrome (47,XXY) NURSING ASSESSMENTS FAMILY HISTORY ASSESSMENT
• Assess family history for other family members with similar reproductive problems/abnormalities. • Inquire about ethnic background (eg, Ashkenazi Jewish populations and hereditary breast/ovarian cancer mutations). • Inquire about relatives with other cancers, including earlyonset ovarian, uterine, renal, prostate cancers. PHYSICAL ASSESSMENT
• In females with delayed puberty or primary amenorrhea, • •
assess for clinical features of Turner syndrome (short stature, webbing of the neck, widely spaced nipples). In males with delayed puberty or infertility, assess for clinical features of Klinefelter syndrome (tall stature, gynecomastia, learning disabilities). Assess for other congenital anomalies in females with Müllerian defect, including renal and vertebral anomalies.
MANAGEMENT ISSUES SPECIFIC TO GENETICS • Inquire whether genetic testing (DNA chromosomal, metabolic) has been carried out on affected family member(s).
Risk for STDs can be assessed by asking about number of partners in the past year or in the patient’s lifetime. An open-ended question related to the patient’s need for further information should be included (eg, “Do you have any questions or concerns about your sexual health?”). Nurses should be aware that some women and men are using the Internet to seek partners; obtaining sexual partners this way has been associated with an increased risk for STDs (McFarlane, Bull & Rietmeijer, 2000; U.S. Department of Health and Human Services, 2001). Young women may be apprehensive about irregular periods, may be concerned about STDs, or may need contraception. They may want information on using tampons, emergency contraception, or issues related to pregnancy. Perimenopausal women may have concerns about irregular menses; menopausal women may be concerned about vaginal dryness and burning with intercourse. Women of any age may have concerns about sexual satisfaction, orgasm or anorgasmia (lack of orgasm).
Female Genital Mutilation Female genital mutilation (FGM) refers to the partial or total removal of the external female genitalia or other injury to female organs. Individuals from some cultures believe that FGM promotes
• If indicated, refer for further genetic counseling and evalu-
• • • •
ation so that family members can discuss inheritance, risk to other family members, availability of genetic testing, and gene-based interventions. Offer appropriate genetics information and resources. Assess patient’s understanding of genetics information. Provide support to families with newly diagnosed generelated reproductive disorders. Participate in management and coordination of care of patients with genetic conditions, individuals predisposed to develop or pass on a genetic condition.
GENETICS RESOURCES FOR NURSES AND THEIR PATIENTS ON THE WEB Genetic Alliance: http://www.geneticalliance.org—a directory of support groups for patients and families with genetic conditions American Cancer Society: http://www.cancer.org—offers general information about cancer and support resources for families Gene Clinics: http://www.geneclinics.org—a listing of common genetic disorders with up-to-date clinical summaries, genetic counseling and testing information National Organization of Rare Disorders: http://www.rarediseases. org—a directory of support groups and information for patients and families with rare genetic disorders National Cancer Institute: http://www.nci.nih.gov—current information about cancer research, treatment, resources for health care providers, individuals and families OMIM: Online Mendelian Inheritance in Man: http://www. ncbi.nlm.nih. gov/omim/stats/html—a complete listing of inherited genetic conditions
hygiene, protects virginity and family honor, prevents promiscuity, improves female attractiveness and male sexual pleasure, and enhances fertility. It is viewed in some cultures as a rite of passage to womanhood. Many organizations (eg, World Health Organization, Amnesty International) are working to end this practice. Four types of FGM are known: excision of the clitoral prepuce; total excision of the clitoral prepuce and glans with partial or total excision of the labia minora; excision of part or all of the external genitalia and stitching or narrowing of the vaginal opening (referred to as infibulation); and unclassified, which includes pricking, piercing, or incision of the clitoris, the labia, or both, stretching of the clitoris or surrounding tissues, and introduction of corrosive substances into the vagina (American College of Obstetricians and Gynecologists [ACOG] Committee Opinion #151, 1995). FGM is usually performed between 4 and 10 years of age; hemorrhage and infection may be consequences. A growing number of women entering the U.S. health care system underwent FGM before coming to this country (Ng, 2000). Others have undergone FGM since they arrived in the United States. Because FGM can affect sexual function, menstrual hygiene, and bladder function, the possibility of FGM is included in the sexual history, particularly for women from cultures and countries where the practice is common.
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Long-term complications of FGM include urinary problems, chronic vaginitis and pelvic infections, inability to undergo pelvic examination, painful intercourse, impaired sexual response, anemia, increased risk for HIV infection due to tearing of scar tissue, and psychological and psychosexual sequelae (American Medical Association, 1995). Nurses who care for patients who have undergone FGM need to be sensitive, empathetic, knowledgeable, and nonjudgmental.
Domestic Violence Domestic violence is a broad term that includes child abuse, elder abuse, and abuse of women and men. Abuse can be emotional, physical, sexual, or economic. Battering involves repeated physical or sexual assault in a context of coercive control and, more broadly, emotional degradation, threats, and intimidation. Nurses need to be aware of the prevalence of abuse and violence directed against women in our society. Abuse is related to the need to maintain control of a partner and involves fear of one partner by another and control by threats, intimidation, and physical abuse. Violence is rarely a one-time occurrence in a relationship; it usually continues
and escalates in severity. This is an important point to emphasize when a woman states that her partner has hurt her but has promised to change. Batterers can change their behavior, but not without extensive counseling and motivation. If a woman states that she is being hurt, sensitive care is required (Chart 46-2). Because more than 6 million women experience domestic violence each year, battered women are encountered daily in nursing practice. By knowing about this major public health problem, being alert to abuse-related problems, and learning how to elicit information from women about abuse in their lives, nurses can offer intervention for a problem that might otherwise go undetected. Asking each woman about violence in her life in a safe environment (ie, a private room with the door closed) is part of a comprehensive assessment and universal screening. The Abuse Assessment Screen has been found effective in identifying the presence of abuse and should be included in the health history of all women (Chart 46-3). No specific signs or symptoms are diagnostic of battering; however, nurses may see an injury that does not fit the account of how it happened (eg, a bruise on the side of the upper arm after “I walked into a door”). Manifestations of abuse may involve suicide attempts, drug and alcohol abuse, frequent emergency de-
Chart 46-2 GUIDELINES FOR Managing Reported Domestic Abuse ACTION
RATIONALE
1. Reassure the woman that she is not alone. 2. Express your belief that no one should be hurt, that abuse is the fault of the batterer and is against the law. 3. Assure the woman that her information is confidential, although it does become part of her medical record. If children are suspected of being abused or are being abused, the law requires that this be reported to the authorities. Some states require reporting of spousal or partner abuse. Domestic violence agencies and medical and nursing groups disagree with this policy and are trying to have it changed. Serious opposition is based on the fact that reporting does not and cannot currently guarantee a woman’s safety and may place her in more danger. It may also interfere with a patient’s willingness to discuss her personal life and concerns with care providers. This places a serious barrier in the way of comprehensive nursing care. If nurses are in doubt, they need to check with their local or state domestic violence agency.) 4. Document the woman’s statement of abuse and take photographs of any visible injuries if written formal consent has been obtained. (Emergency departments usually have a camera available if one is not on the nursing unit.) 5. Provide teaching: • Inform the woman that shelters are available to ensure safety for her and her children. (Lengths of stay in shelters vary by state but are often up to 2 months. Staff often assist with housing, jobs, and the emotional distress that accompanies the break-up of the family.) Provide list of shelters. • Inform woman that violence gets worse, not better. • If the woman chooses to go to a shelter, let her make the call. • If she chooses to return to the abuser, remain nonjudgmental and provide information that will make her safer than she was before disclosing her situation. • Make sure that she has a 24-hour hotline telephone number that provides information and support (Spanish translation and a device for the deaf are also available), police number, and 911. • Assist her to set up a safety plan in case she decides to return home. (A safety plan is an organized plan for departure with packed bags and important papers hidden in a safe spot.)
Many women are hurt by their partners, and nurses see them daily. Let the woman know that no one deserves to be abused. Women are often afraid that their information will be reported to the police or protective services and their children may be taken away.
Provide documentation of injuries that may be needed for later legal or criminal proceedings. These options may be life-saving for the woman and her children.
Chapter 46
Chart 46-3
Assessment and Management of Female Physiologic Processes
Screening for Abuse
The Abuse Assessment Screen consists of the following three questions: 1. In the past year, have you been hit, slapped, kicked, or otherwise physically hurt by someone? 2. If pregnant, since you have been pregnant, have you been hit, slapped, kicked, or otherwise physically hurt by someone? 3. Have you ever been forced into sexual activity?
partment visits, vague pelvic pain, and depression. However, there may be no obvious signs or symptoms. Women in abusive situations often report that they do not feel well, due to the stress of fear and anticipation of abuse. Nurses need to be knowledgeable about abuse, ask every woman patient about abuse in her life, provide resources, and follow written protocols within their institution to ensure comprehensive care.
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for assault. Often, the assailant is a partner, husband, or date. Nurses may encounter women with infections or pregnancies related to sexual assault that were never treated.
Health Issues of Women With Disabilities Studies have shown that women with disabilities receive less primary health care and preventive health screening than other women, often because of access problems and health care providers’ focus on the causes of disability rather than on general health issues of concern to all women. To address these issues, the history should include questions about barriers to health care experienced by disabled women and the effect of their disability on their health status and health care. Other issues to be addressed are identified in Chart 46-4. If the patient has hearing loss, vision loss, or another disability, the nurse may need to obtain the assistance of a signer or interpreter. The nurse assessing a person with a disability may require additional time and the assistance of others to be certain that accurate information is obtained from the patient. Extra time may be needed to conduct the assessment in a sensitive and unhurried manner (Kirschner, Gill, Reis & Welner, 1998; Smeltzer, 2000).
Incest and Childhood Sexual Abuse Because more than one in five women has experienced incest or childhood sexual abuse, nurses frequently encounter women who have been sexually traumatized. It has been reported that female survivors of sexual abuse have more health problems and undergo more surgery than women who were not victimized. Victims of childhood sexual abuse are reported to experience more chronic depression, posttraumatic stress disorder, morbid obesity, marital instability, gastrointestinal problems, and headaches, as well as greater use of health care services, than persons who were not victims. Chronic pelvic pain in women is often associated with physical violence, emotional neglect, and sexual abuse in childhood (ACOG Educational Bulletin #259, 2001). Women who have experienced rape or sexual abuse may have difficulty with pelvic examinations, labor, pelvic or breast irradiation, or any treatment or examination that involves hands-on treatment or requires removal of clothing. Nurses should be prepared to offer support and referral to psychologists, community resources, and self-help groups.
Rape and Sexual Assault Sexual assault occurs every 6 minutes in the United States. Men, women, and children may be victims. Sexual assault nurse examiners, emergency department staff, and gynecologists perform the painstaking collection of forensic evidence that is needed for criminal prosecution. Oral, anal, and genital tissue is examined for evidence of trauma, semen, or infection. Saliva, hair, and fingernail evidence is also collected. Cultures are obtained for STDs, and prophylactic antibiotics are prescribed. HIV testing is offered and is repeated in 3 to 6 months. HIV prophylaxis is not universally recommended but is considered when mucosal exposure to contamination has occurred. Prophylaxis against chlamydia and gonorrhea are provided (Kaplan, Feinstein, Fisher et al., 2001). Emergency contraception is provided if requested. Emotional counseling is provided, and follow-up treatment visits are arranged. Rape trauma syndrome is the emotional reaction to a sexual assault and may consist of shock, sleep disturbances, nightmares, flashbacks, anxiety, anger, mood swings, and depression. It is important for survivors to discuss the experience and to obtain professional counseling. Screening for abuse, rape, and violence should be part of routine assessment because women often do not report or seek treatment
PHYSICAL ASSESSMENT Periodic examinations and routine cancer screening are important for all women. An annual breast and pelvic examination is important for all women age 18 or older and for those who are sexually active, regardless of age. The patient deserves understanding and support because of the emotional and physical considerations associated with gynecologic examinations. Women may be sensitive or embarrassed by the usual questions asked by a gynecologist or women’s health care provider. Because gynecologic conditions are of a personal and private nature to most women, such information is shared only with those directly involved in patient care (as is true with all patient information). Throughout the examination, the nurse explains the procedures to be performed. This not only encourages the woman to relax but also provides an opportunity for her to ask questions and minimizes the negative feelings that many women associate with gynecologic examinations. The first pelvic examination is often anxiety-producing for women; the nurse can alleviate many of these feelings with explanations and teaching (Chart 46-5). Before the examination begins, the patient is asked to empty her bladder and to provide a urine specimen if urine tests are part of the total assessment. Voiding ensures patient comfort and eases the examination because a full bladder can make palpation of pelvic organs uncomfortable for the patient and difficult for the examiner.
Positioning Although several positions may be used for the pelvic examination, the supine lithotomy position is used most commonly, although the upright lithotomy position (in which the woman assumes a semisitting posture) may also be used. This position offers several advantages: • It is more comfortable for some women. • It allows better eye contact between patient and examiner. • It may provide an easier means for the examiner to carry out the bimanual examination. • It enables the woman to use a mirror to see her anatomy (if she chooses) to visualize any conditions that require treatment or to learn about using certain types of contraceptive methods.
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Chart 46-4
REPRODUCTIVE FUNCTION
• ASSESSMENT
Assessing a Woman With a Disability Health History Address questions directly to the woman herself rather than to persons accompanying her. Self-care limitations resulting from her disability (ability to feed and dress self, use of assistive devices, transportation requirements, other assistance needed) Sensory limitations (lack of sensation, low vision, deaf or hard of hearing) Accessibility issues (ability to get to health care provider, transfer to examination table, accessibility of office/clinic of health care provider, previous experiences with health care providers, health screening practices; her understanding of physical examination) Cognitive or developmental changes that affect understanding Limitations secondary to disability that affect general health issues and reproductive health and health care Sexual function and concerns (those of all women and those that may be affected by the presence of a disabling condition) Menstrual history and menstrual hygiene practices Physical, sexual, or psychological abuse (including abuse by care providers) Presence of secondary disabilities (ie, those resulting from the patient’s primary disability: pressure ulcers, spasticity, osteoporosis, etc.) Health concerns related to aging with a disability
In the supine lithotomy position, the patient lies on the table with her feet on foot rests or stirrups. She is encouraged to relax so that her buttocks are positioned at the edge of the examination table, and she is asked to relax and spread her thighs as widely apart as possible. If the patient is too ill, disabled, or neurologically impaired to lie safely on the examination table or cannot maintain the supine lithotomy position, the Sims’ position may be used. In Sims’ position, the patient lies on her left side with her right leg bent at a 90-degree angle. The right labia may be retracted to gain adequate access to the vagina. Other positions for pelvic examination for disabled
Chart 46-5
Physical Assessment Provide instructions directly to the woman herself rather than to persons accompanying her; provide written or audiotaped instructions. Ask the woman what assistance she needs for the physical examination and provide assistance if needed: —Undressing and dressing —Providing a urine specimen —Standing on scale to be weighed (provide alternative means of obtaining weight if she is unable to stand on scale) —Moving on and off the examination table —Assuming, changing, and maintaining positions Consider the fatigue experienced by the woman during a lengthy exam and allow rest. Provide assistive devices and other aids/methods needed to allow adequate communication with the patient (interpreters, signers, large-print written materials). Complete examination that would be indicated for any other woman; having a disability is never justification for omitting parts of the physical examination, including the pelvic examination.
women make the examination easier for the woman and the clinician. The presence of a disability does not justify skipping any parts of the physical assessment, including the pelvic examination. The following equipment is obtained and readily available: a good light source; a vaginal speculum; clean examination gloves; lubricant, spatula, cytobrush, glass slides, fixative solution or spray; and diagnostic testing supplies for screening for occult rectal blood if the woman is older than 40. Latex-free gloves should be available if the patient or clinician is allergic to latex. This allergy is becoming more prevalent in nurses and other health care providers and patients and is potentially life-threatening. Patients should be questioned about previous reactions to latex. (See Chap. 18 for a latex screening form and Chap. 53 for more information on latex allergy.)
Patient Education: The Pelvic Examination
The nurse should explain the following to the patient: • A pelvic examination includes assessment of the appearance, size, and shape of the vulva, vagina, uterus, and ovaries to ensure reproductive health and absence of illness. • A pelvic examination should never hurt except in the presence of a pelvic infection. Women often describe a feeling of fullness or pressure but should not feel pain. Some women who are very tense feel discomfort, so relaxation is important. • It is normal to feel uncomfortable and apprehensive. • A narrow, warmed speculum will be inserted to visualize the cervix. • A Papanicolaou (Pap) smear will be obtained and should not be uncomfortable. • The patient may watch the examination with a mirror if she chooses. • The examination usually takes no longer than 5 minutes. • Draping will be used to minimize exposure (despite appropriate draping, some women feel uncomfortable or embarrassed during the examination).
Inspection After the patient is prepared, the examiner inspects the labia majora and minora, noting the epidermal tissue of the labia majora; the skin fades to the pink mucous membrane of the vaginal introitus. Lesions of any type (eg, venereal warts, pigmented lesions [melanoma]) are evaluated. In the nulliparous woman, the labia minora come together at the opening of the vagina. In women who have delivered children vaginally, the labia minora may gape and vaginal tissue may protrude. Trauma to the anterior vaginal wall during childbirth may have resulted in incompetency of the musculature, and a bulge caused by the bladder protruding into the submucosa of the anterior vaginal wall (cystocele) may be seen. Childbirth trauma may also have affected the posterior vaginal wall, producing a bulge caused by rectal cavity protrusion (rectocele). The cervix may descend under pressure through the vaginal canal and be seen at the introitus (uterine prolapse). See Chapter 47 for a discussion of these structural changes. To identify such protrusions, the examiner asks the patient to “bear down.”
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The introitus should be free of superficial mucosal lesions. The labia minora may be separated by the fingers of the gloved hand and the lower part of the vagina palpated. In virgins, a hymen of variable thickness may be felt circumferentially within 1 or 2 cm of the vaginal opening. The hymenal ring usually permits the insertion of one finger. Rarely, the hymen totally occludes the vaginal entrance (imperforate hymen). In women who are not virgins, a rim of scar tissue representing the remnants of the hymenal ring may be felt circumferentially around the vagina near its opening. The greater vestibular glands (Bartholin’s glands) lie between the labia minora and the remnants of the hymenal ring. An abscess of the Bartholin’s gland can cause discomfort and requires incision and drainage.
the set-screw of the thumb rest is tightened to hold the speculum open (Fig. 46-4).
Speculum Examination
ABNORMAL GROWTH Malignant changes may not be obviously differentiated from the rest of the cervical mucosa. Small, benign cysts may appear on the cervical surface. These are usually bluish or white and are called nabothian cysts. A polyp of endocervical mucosa may protrude through the os and usually is dark red. Polyps can cause irregular bleeding; they are rarely malignant and usually are removed easily in an office or clinic setting. A carcinoma may appear as a cauliflower-like growth that bleeds easily when touched. Bluish coloration of the cervix is a sign of early pregnancy (Chadwick’s sign).
The bivalved speculum, either metal or plastic, is available in many sizes. Metal specula are soaked, scrubbed, and sterilized between patients. Some clinicians and some patients prefer plastic specula, which permit one-time use. The speculum should be warmed with a heating pad or warm water to make insertion more comfortable for the patient. The speculum is not lubricated because commercial lubricants interfere with cervical cytology (Papanicolaou [Pap] smear) findings. The metal speculum has two set-screws. The one along the handle, holding the two valves of the speculum together, is kept tightened. The screw that holds the thumb rest in place is loosened. The speculum is grasped in the dominant hand, with the thumb against the back of the thumb rest to keep the tips of the valves closed. The speculum is rotated slightly counterclockwise, and the vaginal orifice is held open by the thumb and the forefinger of the gloved nondominant hand by some examiners. Other examiners find that straight insertion of a speculum with downward pressure on the vagina is more comfortable for the patient. The speculum is gently inserted into the posterior portion of the introitus and slowly advanced to the top of the vagina; this should not be painful or uncomfortable for the woman. The tip of the speculum may then be elevated and the speculum rotated to a transverse position. The speculum is then slowly opened and
A
FIGURE 46-4
CERVIX The cervix is inspected. In nulliparous women, the cervix usually is 2 to 3 cm wide and smooth. Women who have borne children may have a laceration, usually transverse, giving the cervical os a “fishmouth” appearance. Epithelium from the endocervical canal may have grown onto the surface of the cervix, appearing as beefyred surface epithelium circumferentially around the os. Occasionally, the cervix of a woman whose mother took DES has a hooded appearance (a peaked aspect superiorly or a ridge of tissue surrounding it); this is evaluated by colposcopy when identified.
PAP SMEAR During the pelvic examination, a Pap smear is obtained by rotating a small spatula at the os, followed by a cervical brush rotated in the os. The tissue obtained is spread on a glass slide and sprayed or fixed immediately, or inserted into a liquid. A small broom-like device can also be used to obtain specimens for the Pap smear. A specimen of any purulent material appearing at the cervical os is obtained for culture. A sterile applicator is used to obtain the specimen, which is immediately placed in an appropriate medium for transfer to a laboratory. In patients at high risk for infection, routine cultures for gonococcal and chlamydial organisms are recommended because of the high incidence of both diseases and the high risk for pelvic infection, fallopian tube damage, and subsequent infertility.
B
Technique for speculum examination of the vagina and cervix. (A) The labia are spread apart with a gloved left hand, while the speculum is grasped in the right hand and turned counterclockwise before being inserted into the vagina. Once the speculum is inserted, the blades are then spread apart (B) to reveal the cervical os (C).
C
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Vaginal discharge, which may be normal or may result from vaginitis, may be present. Discharge caused by bacteria (bacterial vaginosis) usually appears gray and purulent. Discharge caused by Trichomonas species infection is usually frothy, copious, and malodorous. Discharge caused by Candida species infection is usually thick and white-yellow and has a cottage-cheese appearance. Table 46-3 summarizes the characteristics of vaginal discharge found in different conditions. The vagina is inspected as the examiner withdraws the speculum. It is smooth in young girls and thickens after puberty, with many rugae (folds) and redundancy in the epithelium. In menopausal women, the vagina thins and has fewer rugae because of decreased estrogen.
Bimanual Palpation To complete the pelvic examination, the examiner performs a bimanual examination from a standing position. The examination is performed with the forefinger and middle finger of the gloved and lubricated hand. These fingers are placed in the vaginal orifice, while the other fingers are held tightly out of the way, with the thumb completely adducted. The fingers are advanced vertically along the vaginal canal, and the vaginal wall is palpated. Any firm part of the vaginal wall may represent old scar tissue from childbirth trauma but may also require further evaluation. CERVICAL PALPATION The cervix is palpated and assessed for its consistency, mobility, size, and position. The normal cervix is uniformly firm but not hard. Softening of the cervix is a finding in early pregnancy. Hardness and immobility of the cervix may reflect invasion by a neoplasm. Pain on gentle movement of the cervix is called a positive chandelier sign or positive cervical motion tenderness (recorded as +CMT) and usually indicates a pelvic infection. UTERINE PALPATION To palpate the uterus, the examiner places the opposite hand on the abdominal wall halfway between the umbilicus and the pubis and presses firmly toward the vagina (Fig. 46-5). Movement of the abdominal wall causes the body of the uterus to descend, and the pear-shaped organ becomes freely movable between the abdominal examining hand and the fingers of the pelvic examining hand. Uterine size, mobility, and contour can be estimated through palpation. Fixation of the uterus in the pelvis may be a sign of endometriosis or malignancy. The body of the uterus is normally twice the diameter and twice the length of the cervix, curving anteriorly toward the abdominal wall. Some women have a retroverted or retroflexed
Table 46-3
FIGURE 46-5
Technique for the bimanual examination of the pelvis.
uterus, which tips posteriorly toward the sacrum, whereas others have a uterus that is neither anterior nor posterior but is midline. ADNEXAL PALPATION Next, the right and left adnexal areas are palpated to evaluate the fallopian tubes and ovaries. The fingers of the hand examining the pelvis are moved first to one side, then to the other, while the hand palpating the abdominal area is moved correspondingly to either side of the abdomen and downward. The adnexa (ovaries and fallopian tubes) are trapped between the two hands and palpated for an obvious mass, tenderness, and mobility. Commonly, the ovaries are slightly tender, and the patient is informed that slight discomfort on palpation is normal. VAGINAL AND RECTAL PALPATION Bimanual palpation of the vagina and cul-de-sac is accomplished by placing the index finger in the vagina and the middle finger in the rectum. To prevent cross-contamination between the vaginal and rectal orifices, the examiner puts on new gloves. A gentle movement of these fingers toward each other compresses the posterior vaginal wall and the anterior rectal wall and assists the examiner in identifying the integrity of these structures. During this procedure, the patient may sense an urge to defecate. The nurse assures the patient that this is unlikely to occur. Ongoing explanations are provided to reassure and educate the patient about the procedure.
• Characteristics of Vaginal Discharge
CAUSE OF DISCHARGE
SYMPTOMS
ODOR
CONSISTENCY/COLOR
Physiologic Candida species infection Bacterial vaginosis Trichomonas species infection Atrophic
None Itching, irritation Odor Irritation, odor Vulvar or vaginal dryness
None Yeast odor or none Fishy, often noticed after intercourse Malodorous Occasional mild malodor
Mucus/white Thin to thick, curdlike/white Thin/grayish or yellow Copious, often frothy/yellow-green Usually scant and mucoid/may be blood-tinged
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Assessment and Management of Female Physiologic Processes
Gerontologic Considerations Yearly examinations can help prevent problems of the reproductive tract in aging women. Some older women do not have regular gynecologic examinations. If a woman delivered her children at home, she may never have had a pelvic examination. Some regard it as an embarrassing and unpleasant procedure. An important role of the nurse is to encourage an annual gynecologic examination for all women. The nurse can make the examination a time for education and reassurance rather than a time of embarrassment. Perineal pruritus is common in elderly women and should be evaluated because it may indicate a disease process (diabetes or malignancy). It may also indicate vulvar dystrophy, a thickened or whitish discoloration of tissue that needs biopsy to rule out abnormal cells. Topical cortisone and hormone creams may be prescribed for symptomatic relief. With relaxing pelvic musculature, uterine prolapse and relaxation of the vaginal walls can occur. Appropriate evaluation and surgical repair can provide relief if the patient is a candidate for surgery. After surgery, the patient needs to know that tissue repair and healing may require additional time. Pessaries (latex devices that provide support) are often used if surgery is contraindicated or before surgery to see if surgery can be avoided. They are fitted by a health care provider and may reduce discomfort and pressure. Use of a pessary requires the patient to have routine gynecologic examinations to monitor for irritation or infection.
Diagnostic Evaluation CYTOLOGIC TEST FOR CANCER (PAP SMEAR) The Pap smear is performed to detect cervical cancer. Before 1940, cervical cancer was the most common cause of cancer death in women. Dr. George Papanicolaou discovered the value of examining exfoliated cells for malignancy in the 1930s. Due to the effectiveness of the Pap smear as a screening method, cervical cancer is now less common than breast or ovarian cancer. Cervical secretions are gently removed from the cervical os (Fig. 46-6), transferred to a glass slide, and fixed immediately by spraying with a fixative. A Thin-prep Pap specimen is immersed in a solution rather than being placed on a slide. This method allows for human papillomavirus (HPV) testing if the Pap smear result is abnormal (see Chap. 47 for further discussion of HPV, a commonly transmitted STD that can cause venereal warts or cervical changes). The patient should be instructed not to douche before this examination to avoid washing away cellular material. The Pap smear should be performed when the patient is not menstruating because blood usually interferes with interpretation. The proper technique for obtaining a cervical specimen for cytologic study is described in Chart 46-6. False-negative Pap smear results may occur, as may false positives. The Bethesda Classification system (Chart 46-7) has been developed to promote consistency in reporting Pap smear results and to assist in standardizing management guidelines (Solomon, Davey, Kurman et al., 2001). Terminology includes the following categories: • Low-grade squamous intraepithelial lesion (LSIL), which is equivalent to cervical intraepithelial neoplasia (CIN 1) and to mild changes related to exposure to HPV
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• High-grade squamous intraepithelial lesions (HSIL), which equates to moderate and severe dysplasia, carcinoma in situ (CIS), and CIN 2 and CIN 3
These terms seen on Pap smear findings encompass the precursors to invasive carcinoma of the cervix. Pap smears that reveal mild inflammation or atypical squamous cells are usually repeated in 3 to 6 months, with findings often returning to normal. Patients are apprehensive because many women incorrectly assume that an abnormal Pap smear means cancer. If a specific infection is causing inflammation, it is treated appropriately, and the Pap smear is repeated. If the repeat Pap smear reveals atypical squamous cells, then a colposcopy is appropriate. Thin-prep Pap specimens that show atypical cells can also be used to determine the presence of HPV DNA. If HPV DNA is present, it is more likely that HSIL is present. If the Pap smear results are abnormal, prompt notification, evaluation, and treatment are crucial. Notification of patients is often done by nurses in women’s health care. Pap smear followup is crucial as it can prevent cervical cancer. Many women do not adhere to recommendations—particularly young women, those of low socioeconomic status, minorities, women who have difficulty coping with the diagnosis, and those without social support. Fear, lack of understanding, and childcare responsibilities have all been identified by women as reasons for poor follow-up. Women with a history of abuse, obese women, and women who had a negative gynecologic experience may also find returning for follow-up difficult (Wee, McCarthy, Davis & Phillips, 2000). Interventions are tailored to meet the needs of the particular group. Intensive telephone counseling, tracking systems, brochures, videos, and financial incentives have all been used to encourage followup. Nurses can provide clear explanations and emotional support along with a carefully designed follow-up protocol designed to meet the needs of their specific patient population (DeRemer Abercrombie, 2001).
COLPOSCOPY AND CERVICAL BIOPSY All suspicious Pap smears should be evaluated by colposcopy. The colposcope is a portable microscope (magnification from 10× to 25×) that allows the examiner to visualize the cervix and obtain a sample of abnormal tissue for analysis. Nurse practitioners and gynecologists require special training in this diagnostic technique. After inserting a speculum and visualizing the cervix and vaginal walls, the examiner applies acetic acid to the cervix. Subsequent abnormal findings that indicate the need for biopsy include leukoplakia (white plaque visible before applying acetic acid), acetowhite tissue (white epithelium after applying acetic acid), punctation (dilated capillaries occurring in a dotted or stippled pattern), mosaicism (a tile-like pattern), and atypical vascular patterns. An endocervical curettage may be performed during colposcopy if a problem is suspected based on Pap smear findings. This analysis of tissue from the cervical canal is used to determine whether abnormal changes have occurred in the cervical canal. If these biopsy specimens show premalignant cells or CIN, the patient usually needs cryotherapy, laser therapy, or a cone biopsy (excision of an inverted tissue cone from the cervix) (ACOG Committee Opinion #195, 1998).
CRYOTHERAPY AND LASER THERAPY Cryotherapy (freezing cervical tissue with nitrous oxide) and laser treatment are used in the outpatient setting. Cryotherapy may result in cramping and occasional feelings of faintness (vasovagal
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A
B
C
D
FIGURE 46-6 Method of using a wooden Ayre spatula to obtain cervical secretions for cytology. (A) Speculum in place and the Ayre spatula in position at the cervical os. (B) The tip of the spatula is placed in the cervical os and the spatula rotated 360 degrees, firmly but nontraumatically. (C) Cellular material clinging to the spatula is then smeared smoothly on a glass slide. (D) Cytobrush is rotated in the cervical os and rolled onto a glass slide. Smear is then sprayed with fixative. Note: Thin-prep (liquid-based) Pap smears are collected in the same way with a spatula and a brush, but then both are swirled separately in a bottle of thin prep solution and sent to the laboratory. response). A watery discharge is normal for a few weeks after the procedure as the cervix heals.
CONE BIOPSY AND LEEP If the endocervical curettage findings indicate abnormal changes or if the lesion extends into the canal, the patient may undergo a cone biopsy. This can be performed surgically or with a procedure called LEEP (loop electrosurgical excision procedure), which uses a laser beam. Usually performed in the outpatient setting, LEEP is associated with a high success rate in removal of abnormal cervical tissue and has a low incidence of complications (ACOG Committee Opinion #195, 1998). The gynecologist excises a small amount of cervical tissue, and the pathologist examines the borders of the specimen to determine if they are free of disease. A patient anes-
thetized for a surgical cone biopsy is advised to rest for 24 hours after the procedure and to leave any vaginal packing in place until the physician removes it (usually the next day). The patient is instructed to report any excessive bleeding. Guidelines regarding postoperative sexual activity, bathing, and other activities are provided by the nurse or the physician. Because open tissue may be potentially exposed to HIV and other pathogens, the patient is usually cautioned to avoid intercourse until healing is complete and verified at follow-up. Cervical stenosis can be a complication of this procedure.
ENDOMETRIAL (ASPIRATION) BIOPSY A tissue sample obtained through biopsy permits diagnosis of cellular changes in the endometrium. Endometrial biopsy, a method of obtaining endometrial tissue, is performed during the pelvic ex-
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Chart 46-6 GUIDELINES FOR Obtaining an Optimal Pap Smear NURSING ACTION
RATIONALE
1. Do not obtain a Pap smear if the woman is menstruating or has other frank bleeding (exception: high suspicion of neoplasia). 2. If performing more than one test (eg, Pap and GC), obtain the Pap smear first. 3. Label the frosted end of the slide with the patient’s name in pencil or label Thin-prep Pap bottle. 4. Put on gloves before gently inserting the unlubricated speculum. (Speculum may be moistened with warm water.) 5. Place the longer end of the Ayre spatula in the cervical canal and rotate it in a full circle to obtain a sample from the exocervix. Spread the material obtained onto the Pap smear slide. 6. Insert a cytobrush 2 cm into the cervical canal and rotate 180 degrees. Roll the brush onto the Pap smear slide. (With Thinprep Pap smears, the brushings are not spread onto a slide. The spatula and brush are placed in a bottle of fixative and swirled.) 7. In women who have had a hysterectomy, use a cotton applicator moistened with saline solution to obtain a sampling of cells from the vaginal cuff or posterior vagina. 8. Immediately spray the slide or, if a Thin-prep, swirl the brush and spatula in the solution.
Blood obscures a proper reading of cells.
amination when indicated as an outpatient procedure. Women undergoing this procedure may experience slight discomfort. Usually, the procedure can be performed without anesthesia; however, a paracervical block or a small injection of lidocaine into the uterus is effective if required. The examiner may apply a tenaculum (a clamp-like instrument that stabilizes the uterus) after the pelvic
By performing the Pap smear first, the chance of a bloody smear is avoided. Ink may rub off or blur. Labeling with a pencil prevents improper identification. Gloves provide protection and warm water prevents discomfort. Lubricants may obscure cells on Pap smear. This technique obtains a sampling of the exocervix and squamocolumnar junction. This obtains endocervical cells and may sample cells from the squamocolumnar junction if it is high in the canal. Saline solution prevents drying, which makes interpretation difficult for the cytologist and prevents absorption of cells into the cotton, increasing the yield on the slide. Exposure to air or light causes distortion of cells.
examination and then inserts a thin, hollow, flexible suction tube (pipelle or sampler) through the cervix into the uterus. Endometrial biopsy is usually indicated in cases of midlife irregular bleeding, postmenopausal bleeding, and infertility (to identify changes in the uterine lining after ovulation). Women who are bleeding irregularly while receiving hormone replacement
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therapy or who experience any bleeding while taking tamoxifen are usually advised to undergo endometrial biopsy. Findings on aspiration may include normal endometrial tissue, hyperplasia, or endometrial cancer. Simple hyperplasia is an overgrowth of the uterine lining and is usually treated with progesterone. Complex hyperplasia is a risk factor for uterine cancer and is treated with progesterone and careful follow-up. Women who are overweight, who are over 45, who have a history of nulliparity and infertility, and who have a family history of colon cancer seem to be at higher risk for hyperplasia (Farquhar, Lethaby, Sowter et al., 1999). Endometrial cancer is discussed in Chapter 47.
DILATION AND CURETTAGE A dilation and curettage (D & C) may be diagnostic (identifies the cause of irregular bleeding) or therapeutic (often temporarily stops irregular bleeding). The cervical canal is widened with a dilator and the uterine endometrium is scraped with a curette. The purpose of the procedure is to secure endometrial or endocervical tissue for cytologic examination, to control abnormal uterine bleeding, and as a therapeutic measure for incomplete abortion. Because this procedure is usually carried out under anesthesia and requires surgical asepsis, it is usually performed in the operating room. However, it may take place in the outpatient setting with the patient receiving a local anesthetic supplemented with diazepam (Valium), midazolam (Versed), or meperidine (Demerol). The patient who receives these medications is carefully monitored until she has fully recovered. The nurse provides an explanation of the procedure as well as physical and psychological preparation, informing the patient about what the procedure involves and what to expect in terms of postoperative discomfort and bleeding. The perineum is not shaved, but the patient is instructed to void before the procedure. The patient is placed in the lithotomy position, the cervix is dilated with a dilating instrument, and endometrial scrapings are
obtained by a curette. A perineal pad is placed over the perineum after the procedure, and excessive bleeding is reported. No restrictions are placed on dietary intake. If pelvic discomfort or low back pain occurs, mild analgesics usually provide relief. The physician indicates when sexual intercourse may be safely resumed. To reduce the risk of infection and bleeding, most physicians advise no vaginal penetration or use of tampons for 2 weeks.
ENDOSCOPIC EXAMINATIONS Laparoscopy (Pelvic Peritoneoscopy) A laparoscopy involves inserting a laparoscope (a tube about 10 mm wide and similar to a small periscope) into the peritoneal cavity through a 2-cm (0.75-inch) incision below the umbilicus to allow visualization of the pelvic structures (Fig. 46-7). Laparoscopy may be used for diagnostic purposes (eg, in cases of pelvic pain when no cause can be found) or treatment. Laparoscopy also facilitates many surgical procedures, such as tubal sterilization, ovarian biopsy, myomectomy, and lysis of adhesions (scar tissue that can cause pelvic discomfort). A surgical instrument (intrauterine sound or cannula) may be positioned inside the uterus to permit manipulation or movement during laparoscopy, affording better visualization. The pelvic organs can be visualized after the injection of a prescribed amount of carbon dioxide intraperitoneally into the cavity. Called insufflation, this technique separates the intestines from the pelvic organs. If the patient is undergoing sterilization, the fallopian or uterine tubes may be electrocoagulated, sutured, or ligated and a segment removed for histologic verification (clips are an alternative device for occluding the tubes). After the laparoscopy is completed, the laparoscope is withdrawn, carbon dioxide is allowed to escape through the outer cannula, the small skin incision is closed with sutures or a clip, and the incision is covered with an adhesive bandage. The patient is carefully monitored for several hours to detect any untoward signs indicating bleeding (most commonly from vascular injury
FIGURE 46-7
Laparoscopy. The laparoscope (right) is inserted through a small incision in the abdomen. A forceps is inserted through the scope to grasp the fallopian tube. To improve the view, a uterine cannula (left) is inserted into the vagina to push the uterus upward. Insufflation of gas creates an air pocket (pneumoperitoneum), and the pelvis is elevated (note the angle), which forces the intestines higher in the abdomen.
Chapter 46
Assessment and Management of Female Physiologic Processes
to the hypogastric vessels), bowel or bladder injury, or burns from the coagulator. These complications are rare, making laparoscopy a cost-effective and safe short-stay procedure. The patient may experience abdominal or shoulder pain related to the use of carbon dioxide gas.
Hysteroscopy Hysteroscopy (transcervical intrauterine endoscopy) allows direct visualization of all parts of the uterine cavity by means of a lighted optical instrument. The procedure is best performed about 5 days after menstruation stops, in the estrogenic phase of the menstrual cycle. The vagina and vulva are cleansed, and a paracervical anesthetic block is performed or lidocaine spray is used. The instrument used for the procedure, a hysteroscope, is passed into the cervical canal and advanced 1 or 2 cm under direct vision. Uterine-distending fluid (normal saline solution or 5% dextrose in water) is infused through the instrument to dilate the uterine cavity and enhance visibility. Hysteroscopy is most commonly indicated as an adjunct to a D & C and laparoscopy in cases of infertility, unexplained bleeding, retained intrauterine device (IUD), and recurrent early pregnancy loss. Treatment for some conditions (eg, fibroid tumors) can be accomplished during this procedure. Hysteroscopy is contraindicated in patients with cervical or endometrial carcinoma or acute pelvic inflammation. Endometrial ablation (destruction of the uterine lining) is performed with a hysteroscope and laser beam in cases of severe bleeding not responsive to other therapies. Performed in an outpatient setting, this rapid procedure is an alternative to hysterectomy for some patients. Hysteroscopy, a safe procedure with few complications, has been found to be useful for evaluating endometrial pathology. Uterine perforation can occur.
OTHER DIAGNOSTIC PROCEDURES Many diagnostic procedures are helpful in evaluating pelvic conditions. These may include x-rays, barium enemas, gastrointestinal x-ray series, intravenous urography, and cystography studies. Additionally, because the uterus, ovaries, and fallopian tubes are near the kidneys, ureters, and bladder, urologic diagnostic studies, such as the KUB (kidney, ureter, and bladder) and pyelography are used, as are angiography and radioisotope scanning, if needed. Other diagnostic procedures include hysterosalpingography and computed tomography (CT) scanning.
Hysterosalpingography or Uterotubography Hysterosalpingography is an x-ray study of the uterus and the fallopian tubes after injection of a contrast agent. The diagnostic procedure is performed to evaluate infertility or tubal patency and to detect any abnormal condition in the uterine cavity. Sometimes the procedure is therapeutic because the flowing contrast agent flushes debris or loosens adhesions. In preparation for hysterosalpingography, the intestinal tract is cleansed with cathartics and an enema so that gas shadows do not distort the x-ray findings. An analgesic agent may be prescribed. The patient is placed in the lithotomy position and the cervix is exposed with a bivalved speculum. A cannula is inserted into the cervix and the contrast agent is injected into the uterine cavity and the fallopian tubes. X-rays are taken to show the path and the distribution of the contrast agent. Some patients experience nausea, vomiting, cramps, and faintness. After the test, the patient is advised to wear a perineal
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pad for several hours because the radiopaque agent may stain clothing.
CT Scan CT scanning has several advantages over ultrasonography (described below), even though it involves radiation exposure and is more costly. It is more effective than ultrasonography for obese patients or patients with a distended bowel. A CT scan can also demonstrate a tumor and any extension into the retroperitoneal lymph nodes and skeletal tissue, although it has limited value in diagnosing other gynecologic abnormalities.
Ultrasonography Ultrasonography (or ultrasound) is a useful adjunct to the physical examination, particularly in the obstetric patient or the patient with abnormal pelvic examination findings. It is a simple procedure based on sound wave transmission that uses pulsed ultrasonic waves at frequencies exceeding 20,000 Hz (formerly cycles per second). A transducer placed in contact with the abdomen (abdominal scan) or a vaginal probe (vaginal ultrasound) converts mechanical energy into electrical impulses, which in turn are amplified and recorded on an oscilloscope screen while a photograph or video recording of the patterns is taken. The entire procedure takes about 10 minutes and involves no ionizing radiation and no discomfort other than a full bladder, which is necessary for good visualization during an abdominal scan. (A vaginal ultrasound or sonogram does not require a full bladder.) Saline may be instilled into the uterus (saline infusion sonogram) to help delineate endometrial polyps or fibroids. Polyps are a frequent benign cause of bleeding in older women and can be removed by polypectomy.
Magnetic Resonance Imaging Magnetic resonance imaging (MRI) produces patterns that are finer and more definitive than other imaging procedures without exposing the patient to radiation. MRI, however, is more costly.
Management of Normal and Altered Female Physiologic Processes Many health concerns of women are related to normal changes or abnormalities of the menstrual cycle. Many result from women’s lack of understanding of the menstrual cycle, developmental changes, and factors that may affect the pattern of the menstrual cycle. Educating women about the menstrual cycle and changes over time is an important aspect of the nurse’s role in providing quality care to women. Teaching should begin early, so that menstruation and the lifelong changes in the menstrual cycle can be anticipated and accepted as a normal part of life.
MENSTRUATION Menstruation, a cyclic vaginal flow of tissue that lines the uterus, occurs about every 28 days during the reproductive years, although normal cycles can vary from 21 to 42 days. The flow usually lasts 4 to 5 days, during which time 50 to 60 mL (4 to 12 teaspoons) of blood are lost. A perineal pad is generally used to absorb menstrual discharge; deodorant-treated pads are available, but some women are allergic
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or sensitive to the deodorants. Tampons are also used extensively; there is no significant evidence of untoward effects from their use, provided that there is no difficulty in inserting them. However, tampons should not be used for more than 4 to 6 hours, nor should superabsorbent tampons be used because of the association with toxic shock syndrome (see Chap. 47 for more about this syndrome). If a tampon is hard to remove, the vagina feels dry, or the tampon shreds when removed, less absorbent tampons should be used. If the string breaks or retracts, a woman should squat in a comfortable position, insert one finger into the vagina, try to locate the tampon, and remove it. If the woman feels uncomfortable attempting this maneuver or if she cannot remove the tampon, she should consult a health care provider.
Psychosocial Considerations Girls who are approaching menarche (the onset of menstruation) should be instructed about the normal process of the menstrual cycle before it occurs. Psychologically, it is much healthier to refer to this event as a “period” rather than as “being sick.” With adequate nutrition, rest, and exercise, most women feel little discomfort, although some report breast tenderness and a feeling of fullness 1 or 2 days before menstruation begins. Others report fatigue and some discomfort in the lower back, legs, and pelvis on the first day and temperament or mood changes. Slight deviations from a usual pattern of daily living are considered normal, but excessive deviation may require evaluation. Regular exercise and a low-fat vegetarian diet have been found to decrease discomfort. Heating pads may be very effective for cramps, as may nonsteroidal anti-inflammatory drugs (NSAIDs). The patient with excessive cramping or dysmenorrhea is referred to a gynecologist; oral contraceptives may be prescribed following evaluation.
Cultural Considerations The United States is becoming more culturally diverse. Culture can be defined as the thoughts, communications, actions, customs, beliefs, and values of a racial, ethnic, religious, or social group. These aspects of culture affect many health care encounters, and these encounters can be positive if nurses understand the various cultures of their patients.
Chart 46-8
Differing cultural views and beliefs on menstruation exist. Some women believe that it is detrimental to change a pad or tampon too frequently; they think that allowing the discharge to accumulate increases the flow, which is considered desirable. Some women believe they are vulnerable to illness during menstruation. Others feel it is harmful to swim, shower, have their hair permed, have their teeth filled, or eat certain foods during menstruation. They may also avoid using contraception. In such situations, the nurse is in a position to provide women with facts in an accepting and culturally sensitive manner. The objective is to be mindful of these unexpressed, deep-rooted beliefs and to provide the facts with care. Aspects of gynecologic problems cannot always be expressed easily. The nurse needs to convey confidence and openness and to offer facts to facilitate communication. Suggestions to improve care include overcoming language barriers, providing language-appropriate materials, asking about traditional beliefs and dietary practices, and asking patients about their fears regarding care (Mattson, 2000). Patience, sensitivity, and a desire to learn about other cultures and groups will enhance the nursing care of all women (Chart 46-8).
PERIMENOPAUSE Perimenopause is the period extending from the first signs of menopause—usually hot flashes, vaginal dryness, and irregular menses—to beyond the complete cessation of menses. It has also been defined as the period around menopause, lasting to 1 year after the last menstrual period. Women often have varied beliefs about aging, and these must be considered by the nurse caring for or educating perimenopausal patients.
Nursing Management Perimenopausal women often benefit from information about the subtle physiologic changes they are experiencing. Perimenopause has been described as an opportune time for teaching women about health promotion and disease prevention strategies. When discussing health-related concerns with midlife women, nurses should consider the following issues:
• Sexuality, fertility, contraception, STDs
Lesbian Health Care
Lesbians can generally be defined as women who have sex with or primary emotional partnerships with women, but there is no universally accepted definition; variability exists in relationships and sexual preferences. Lesbians are found in every ethnic group and socioeconomic class. They can be single, celibate, divorced, teens, and seniors. Most experts believe that sexual orientation is not a conscious choice. Lesbians have often encountered insensitivity in health care encounters. When they are asked if they are sexually active and respond affirmatively, contraception is immediately urged as health care providers may assume incorrectly that they practice heterosexual intercourse. Similar to many other marginalized groups of women, they often underuse health care. Some health care providers are homophobic, and discrimination against lesbians has been found in health care (Blackwell & Blackwell, 1999). Nurses need to consider lesbian-
ism within the continuum of human sexual behavior and need to use gender-neutral questions and terms that are non-judgmental and accepting. Lesbian teens are at risk for suicide and STDs. Many lesbians do participate in heterosexual activity and often consider themselves at low risk for STDs. Because HPV, herpes infections, and other organisms implicated in STDs are transmitted by secretions and contact, they may need information on STDs and contraception. If sex toys are used and not cleaned, pelvic infections can occur. Lesbians may smoke and drink more alcohol, may have a higher body mass index, may bear fewer or no children, and often have fewer health preventive screenings than heterosexual women (Carroll, 1999). These factors may predispose them to colon, lung, endometrial, ovarian, and breast cancer, as well as cardiovascular disease and diabetes. Nurses need to understand the unique needs of this population and provide appropriate and sensitive care.
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• Unintended pregnancy (this is possible if contraception is •
•
not used) Oral contraceptive use. Oral contraceptives provide perimenopausal women with protection against uterine cancer, ovarian cancer, anemia, pregnancy, and fibrocystic breast changes as well as relief from perimenopausal symptoms. This option should be discussed with perimenopausal women. (Women who smoke and who are 35 or older should not take oral contraceptives because of an increased risk for cardiovascular disease.) Breast health. About 16% of cases of breast cancer occur in this group of women, so breast self-examination, routine physical examinations, and mammograms are essential.
Women need to be aware that diet and exercise are crucial to their health. The Women’s Health Initiative study has found that the risks of long-term use of hormone replacement therapy (HRT) outweigh the benefits. Although HRT decreases hot flashes and reduces the risk for osteoporotic fractures and colorectal cancer, it increases the risk for breast cancer, heart attack, stroke, and blood clots (Writing Group for Women’s Health Initiative Investigators, 2002). (It has been suggested that the term “menopausal hormone therapy” be used in place of HRT.)
MENOPAUSE Menopause is the permanent physiologic cessation of menses associated with declining ovarian function; during this time, reproductive function diminishes and ends. Postmenopause is the period beginning from about 1 year after menses cease. Menopause is associated with some atrophy of breast tissue and genital organs, loss in bone density, and vascular changes. Menopause starts gradually and is usually signaled by changes in menstruation. The monthly flow may increase, decrease, become irregular, and finally cease. Often, the interval between periods is longer; a lapse of several months between periods is not uncommon. Changes signaling menopause begin to occur as early as the late 30s, when ovulation occurs less frequently, estrogen levels fluctuate, and FSH levels rise in an attempt to stimulate estrogen production.
Clinical Manifestations Because of these hormonal changes, some women notice irregular menses, breast tenderness, and mood changes long before menopause occurs. The hot or warm flashes and night sweats reported by some women are directly attributable to hormonal changes. Hot flashes, which denote vasomotor instability, may vary in intensity from a barely perceptible warm feeling to a sensation of extreme warmth accompanied by profuse sweating, causing discomfort, sleep disturbances and subsequent fatigue, and embarrassment. Other physical changes may include atrophic changes and osteoporosis (decreased bone density), resulting in decreased stature and bone fractures. About 1.5 million new fractures due to osteoporosis occur yearly in the United States (NIH Consensus Statement, 2001). The entire genitourinary system is affected by the reduced estrogen level. Changes in the vulvovaginal area may include a gradual thinning of pubic hair and a slow shrink-
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age of the labia. Vaginal secretions decrease, and the woman may report dyspareunia (discomfort during intercourse). The vaginal pH rises during menopause, predisposing the woman to bacterial infections (atrophic vaginitis). Discharge, itching, and vulvar burning may result. Some women report fatigue, dizziness, forgetfulness, weight gain, irritability, trouble sleeping, feeling “blue,” and feelings of panic. Menopausal complaints need to be evaluated carefully as they may indicate other disorders.
Psychological Considerations Women’s reactions and feelings related to loss of reproductive capacity may vary (Jacob’s Institute of Women’s Health, 2000). For women with grown families, menopause may result in role confusion or feelings of sexual and personal freedom. Women may be relieved that the childbearing phase of their lives is over. Each woman’s circumstances will affect her response and must be considered on an individual basis. Nurses need to be aware of and sensitive to all possibilities and take their cues from the patient.
Medical Management As stated earlier, menopause may be characterized by decreased vaginal secretions, hot flashes, changes in the urinary tract, and mood swings. Decreased vaginal lubrication may cause dyspareunia in the menopausal woman; this may be prevented by the use of a water-soluble lubricant (eg, K-Y jelly, Replens, Astro-Glide, or contraceptive foam or jelly). A vaginal cream containing estrogen or an estrogen-containing vaginal ring may be prescribed. Women approaching menopause often have many concerns about their health. Some have concerns based on a family history of heart disease, osteoporosis, or breast cancer. Each woman should discuss her concerns and feelings with her primary health care provider so that she can make an informed decision about managing menopausal symptoms and maintaining her health. PHARMACOLOGIC THERAPY Hormone Replacement Therapy. HRT reduces or eliminates persistent and severe hot flashes, reduces bone loss, decreases the risk for colon cancer, and improves lipoproteins and lowers fibrinogen levels (Hulley, Grady, Bush, et al., 1998). Despite these findings, the more recent Women’s Health Initiative controlled trial of HRT in over 16,600 women demonstrated that the risks of HRT outweigh the benefits (Writing Group of the Women’s Health Initiative Investigators, 2002). This study was halted after 5.2 years rather than continuing it for the planned duration of 8.5 years because women receiving HRT had a higher risk for invasive breast cancer than the group receiving placebo. Although the absolute risk of breast cancer is low for an individual woman taking HRT, the risks were considered contrary to its intended effect, which is to preserve health and prevent disease. Because of these findings, many women have elected to discontinue HRT, and many of those who previously would have taken HRT have refused or are reluctant to consider it. Some women and their health care providers have elected to begin or continue use of HRT to treat menopausal symptoms because of its benefits. Nurses need to be knowledgeable about the issues associated with
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HRT use if they are to provide appropriate health care to perimenopausal and menopausal women. Risks and Benefits of HRT. The changes that occur during menopause have adverse effects on women, placing them at increased risk for atherosclerosis, angina, and coronary artery disease. The effectiveness of HRT in reducing the risk for some of these conditions has not been supported, and the American Heart Association has recommended against initiating HRT for primary and secondary prevention of cardiovascular disease or stroke (American Heart Association, 2002). HRT is contraindicated in women with a history of breast cancer, vascular thrombosis, active liver disease or chronically impaired liver function, some cases of uterine cancer, and undiagnosed abnormal vaginal bleeding. The risk of thromboembolic phenomena is slightly elevated. Women who elect to take HRT despite these risks should be taught the signs and symptoms of deep vein thrombosis and pulmonary embolism and should be instructed to report these signs and symptoms immediately. Nurses should assess for leg redness, tenderness, chest pain, and shortness of breath in patients who take HRT. Further, women taking HRT need to be informed about the need for follow-up and monitoring. For women who decide to take HRT, regular follow-up care, including a yearly physical examination and mammogram, is important. An endometrial biopsy is indicated for women with any irregular bleeding during treatment. Because the risk of complications increases the longer HRT is used, HRT should be used for the shortest time necessary (American Heart Association, 2002). Making a Decision About HRT. The decision of whether to use HRT has been a difficult one for many women. Although the results of the Women’s Health Initiative trial may make the decision easier for some women, it is likely to remain a difficult decision for those who may benefit from its use because of very disruptive symptoms of menopause and evidence of bone loss. Women often want to learn about alternatives to HRT use; therefore, nurses should address other strategies that women can use to promote their health in the perimenopausal period. Method of HRT Administration. There are several different approaches for use of hormone replacement. Some women take both estrogen and progestin daily; others take estrogen for 25 consecutive days each month, with progestin taken in cycles (eg, 10 to 14 days of the month). Progestin is taken to prevent proliferation of the uterine lining and hyperplasia in women who have not had their uterus removed. Women who take hormones for 25 days often experience bleeding after completing the progestin. Other women take estrogen and progesterone every day and usually experience no bleeding. They occasionally have irregular spotting, which should be evaluated by their health care provider. Estrogen patches, which are replaced once or twice weekly, are another option but require a progestin along with them if the woman still has a uterus. Vaginal treatment with an estrogen cream, suppository, or an estradiol vaginal ring (Estring) may be used for vaginal dryness or atrophic vaginitis. Estring is a small, flexible vaginal ring that slowly releases estrogen in small doses over 3 months. Alternatives to HRT. Women may benefit from learning about alternatives to HRT, including diet, vitamins, and exercise. They need to know that these approaches to menopause have not been examined thoroughly through research. Osteoporosis, a disease characterized by low bone mass and microarchitectural deterio-
ration of bone tissue, occurs with menopause and leads to enhanced bone fragility and increased risk for fracture. Other factors that increase a woman’s risk for osteoporosis include a thin body frame, race (Caucasian or Asian), family history of osteoporosis, nulliparity, early menopause, moderate to heavy alcohol ingestion, smoking, caffeine use, sedentary lifestyle, and a diet low in calcium. Women should be advised to remain active or to begin an exercise program of weight-bearing activity, such as walking; to take a calcium supplement; to decrease or stop smoking; and to discuss the use of pharmacologic agents (bisphosphonates, calcitonin, parathyroid hormone, HRT) to reduce bone loss with their health care provider (NIH Consensus Statement, 2001; National Osteoporosis Foundation, 1999). Selective estrogen receptor modulators (SERMs) such as raloxifene (Evista) provide another alternative to HRT for the prevention and treatment of osteoporosis. These medications do not appear to increase the risk for breast cancer; indeed, the risk of breast and uterine cancer may be reduced. Their use may increase hot flashes. No long-term studies exist on these medications because of their recent development. Osteoporosis and its treatment are described in detail in Chapter 68. Problematic hot flashes have been treated with venlafaxine (Effexor), paroxetine (Paxil), gabapentin (Neurontin), and clonidine (Catapres). These medications have been found to reduce hot flashes and are alternatives for women who do not wish to use HRT. The web site of the North American Menopause Society (http://www.menopause.org) provides additional suggestions. Vitamin B in doses of less than 200 mg has been found to relieve some distressing menopausal symptoms. Vitamin E has been effective in decreasing hot flashes for many women. Some women are interested in alternative treatments (eg, natural estrogens and progestins, black cohosh, ginseng, dong quai, soy products, and several other herbal preparations); however, few scientific data exist about the safety or effectiveness of these remedies. Assessment of menopausal patients should include their use of complementary and alternative therapies and supplements. Medications, including alendronate (Fosamax), raloxifene (Evista), and calcitonin, for the treatment of osteoporosis have given women another option in preventing or treating this major health problem. The American Heart Association (2002) suggests the use of established methods of treatment to lower heart disease risk in women. These include lifestyle changes and behavioral strategies. Pharmacologic therapy (eg, aspirin, beta blockers, statins, angiostatin-converting enzyme inhibitors) may be indicated in women who have cardiovascular disease or are at high risk for it. See Chapter 26 for a more detailed discussion of treatment and prevention of cardiovascular disease. BEHAVIORAL STRATEGIES Regular physical exercise, including weight-bearing exercise, raises the heart rate, increases high-density lipoprotein (HDL) levels, and helps to maintain bone mass. It may also reduce stress, enhance well-being, and improve self-image. Loss of muscle tissue is mediated by exercise; weight-bearing exercise (eg, walking, jogging) at least four times a week is recommended. NUTRITIONAL THERAPY Women should also be encouraged to decrease caloric intake, decrease fat intake, and increase intake of whole grains, fiber, fruit, and vegetables. Women of all ages are urged to include high-calcium food in their diets daily. For example, 1 cup of milk contains about 300 mg of calcium, and 1 cup of nonfat yogurt provides 415 mg of
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calcium. Other sources of dietary calcium include most green leafy vegetables, seafood, and calcium-fortified foods. Calcium supplementation may be helpful in reducing bone loss and preventing the morbidity associated with fractures secondary to osteoporosis. Bones serve as a storehouse of the body’s calcium, and bone density decreases with age. When calcium levels in the blood are low, the bones give up calcium to maintain homeostasis. Women of all age groups often ingest less than the recommended amount of calcium. The average calcium intake is 300 to 500 mg/day, whereas the recommended amount is 1,300 mg/day for adolescents and young adults, 1,000 mg/day for adults 19 to 50 years of age, 1,200 mg/day for adults 51 years of age and older (including menopausal women taking HRT), and 1,500 mg/day for women who are menopausal and not taking HRT (National Osteoporosis Foundation, 1999; NIH Consensus Statement, 2001).
Nursing Management Nurses can encourage women to view menopause as a natural change resulting in freedom from menses and symptoms related to hormonal changes. No relationship exists between menopause and mental health problems; however, social circumstances
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(eg, adolescent children, ill partners, and dependent or ill parents) that usually coincide with menopause may produce stress. Measures should be taken to promote general health. The nurse can explain to the patient that cessation of menses is a physiologic function that is rarely accompanied by nervous symptoms or illness. The current expected life span after menopause for the average woman is 30 to 35 years, which may encompass as many years as the childbearing phase of her life. Menopause is not a complete change of life, however. Normal sexual urges continue, and women retain their usual response to sex long after menopause. Many women enjoy better health after menopause than before, especially those who have experienced dysmenorrhea. The individual woman’s evaluation of herself and her worth, now and in the future, is likely to affect her emotional reaction to menopause. Patient teaching and counseling regarding healthy lifestyles, health promotion, and health screening are of paramount importance (Chart 46-9).
PREMENSTRUAL SYNDROME Premenstrual syndrome (PMS) is a combination of symptoms that occur before the menses and subside with the onset of menstrual flow (Chart 46-10). The cause is unknown, but serotonin
Chart 46-9 Home Care Checklist • The Woman Approaching Menopause At the completion of the home care instruction, the patient or caregiver will be able to: • Describe menopause as a normal period in a woman’s life. • State that fatigue and stress may worsen hot flashes. • State that a nutritious diet and weight control will enhance physical and emotional well-being. • State the importance of exercising for 30 minutes three or four times a week to maintain good health. • Describe involvement in outside activities as beneficial in reducing anxiety and tension. • Identify the following as changes that often occur in midlife: departure of children, aging, dependence of parents, possible loss of loved ones. • Describe this phase of life as having the potential for intellectual growth, personal accomplishment, and initiation of new activities. • State the following points about sexual activity: Frequent sexual activity helps to maintain the elasticity of the vagina. Contraception is advised until 1 year passes without menses. Safer sex is important at any age. Sexual functioning may be enhanced at midlife. • Identify the importance of an annual physical examination to screen for problems and to promote general health. • Identify strategies and methods to prevent or manage the following problems: Itching or burning of vulvar areas: see primary health care provider to rule out dermatologic abnormalities and, if appropriate, to obtain a prescription for a lubricating or hormonal cream. Dyspareunia (painful intercourse) due to vaginal dryness; use a water-soluble lubricant, such as K-Y Jelly, Astro-Glide, Replens, hormone cream, or contraceptive foam. Decreased perineal muscle tone and bladder control: practice Kegel exercises daily (contract the perineal muscles as though stopping urination; hold for 5–10 seconds and release; repeat frequently during the day). Dry skin: use mild emollient skin cream and lotions to prevent dry skin. Weight control: join a weight-reduction support group such as Weight Watchers or a similar group if appropriate, or consult a registered dietitian for guidance about the tendency to gain weight, particularly around the hips, thighs, and abdomen. Osteoporosis: observe recommended calcium and vitamin D intake, including calcium supplements, if indicated, to slow the process of osteoporosis; avoid smoking, alcohol, and excessive caffeine, all of which increase bone loss. Perform weight-bearing exercises. Have bone density testing when appropriate. Risk for urinary tract infection (UTI): drink 6 to 8 glasses of water daily and take vitamin C (500 mg) as a possible way to reduce the incidence of UTI related to atrophic changes of the urethra. Vaginal bleeding: report any bleeding after 1 year of no menses to a primary health care provider immediately, no matter how minimal.
Patient
Caregiver
✓ ✓ ✓ ✓ ✓
✓ ✓ ✓ ✓ ✓
✓
✓
✓
✓
✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓
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Chart 46-10
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Causes, Manifestations, and Treatment of Premenstrual Syndrome
Cause Unknown; may be related to hormonal changes combined with other factors (diet, stress, and lack of exercise) Many women have some symptoms related to menses, but PMS affects 2% to 5% of women and is a complex of symptoms that result in dysfunction. Physical Symptoms Fluid retention (eg, bloating, breast tenderness) Headache Swelling Affective Symptoms Depression Anger Irritability Anxiety
regulation is currently the most plausible theory. Other hormones may also be involved. Dietary factors may play a role because carbohydrates may affect serotonin. Severe symptoms have been labeled as premenstrual dysphoric disorder (DiCarlo, Palomba, Tommaselli et al., 2001; Morse, 1999). This severe form of PMS, which interferes with the woman’s schoolwork, job, or social or family life, is uncommon.
Clinical Manifestations Major symptoms of PMS include headache, fatigue, low back pain, painful breasts, and a feeling of abdominal fullness. General irritability, mood swings, fear of losing control, binge eating, and crying spells may also occur. Symptoms vary widely from one woman to another and from one cycle to the next in the same person. Great variability is found in the degree of symptoms. Many women are affected to some degree, but few are severely affected. Many women are not bothered at all, whereas some experience severe and disabling symptoms (Morse, 1999). A generally stressful life and problematic relationships may be related to the intensity of physical symptoms. Some women report moderate to severe life disruption secondary to PMS that negatively affects their interpersonal relationships. PMS may also be a factor in reduced productivity, work-related accidents, and absenteeism. Identifying the time when these symptoms occur helps in determining the diagnosis. Symptoms recur regularly at the same phase of each menstrual cycle, usually 1 week to a few days before menses, and subside once the menstrual flow starts.
Medical Management Because there is no single treatment or known cure for PMS, the woman should chart her symptoms so she can possibly anticipate and therefore cope with them. Exercise is encouraged for all patients as noncontrolled studies have shown a benefit. Many practitioners advise women to avoid caffeine, high-fat foods, and refined sugars, but there is little research to demonstrate the efficacy of dietary changes. Alternative therapies that women have used include vitamins B and E, magnesium, and oil of evening
Confusion Withdrawal Symptoms begin in the 5 days preceding menses and relief is within 4 days of onset of menses. Dysfunction usually occurs in relationships, parenting, work, or school. Treatment Use of social support and family resources Nutritious diet consisting of whole grains, fruits, and vegetables; increased water intake may help. Serotonin reuptake inhibitors Alprazolam (Xanax) has been effective but is addictive. Spironolactone, a diuretic, may be effective in treating fluid retention. Initiation/maintenance of exercise program. Stress reduction techniques.
primrose capsules. No studies have evaluated the effectiveness of these therapies. PHARMACOLOGIC THERAPY Pharmacologic remedies include selective serotonin reuptake inhibitors (eg, fluoxetine [Prozac, Sarafem]), gonadotropin-releasing hormone agonists, prostaglandin inhibitors (eg, ibuprofen and naproxen [Anaprox]), and antianxiety agents. Some clinicians prescribe analgesic agents, diuretic medications, and natural and synthetic progesterones, although the long-term risks of progesterone use are unknown. Many women find over-the-counter carbohydrate products useful; they provide complex carbohydrates along with vitamins and minerals. Ratios of serum levels of tryptophan to other amino acids are elevated in patients who use tryptophan. It may relieve psychological symptoms and food cravings. Calcium (1,200 mg/day) has been found to be effective, as has magnesium (200 to 400 mg/day).
Nursing Management The nurse should establish rapport with the patient and obtain a health history, noting the time when symptoms began and their nature and intensity. The nurse then determines whether the onset of symptoms occurs before or shortly after the menstrual flow begins. Additionally, the nurse can show the patient how to develop a chart to record the timing and intensity of symptoms. A nutritional history is also elicited to determine if the diet is high in salt, caffeine, or alcohol or low in essential nutrients. The patient’s goals may include reduction of anxiety (mood swings, crying, binge eating, fear of losing control), ability to cope with day-to-day stressors and relationships with family and coworkers, and increased knowledge about PMS with improved use of control measures. Positive coping measures are facilitated. Partners can be advised to assist by offering support and increased involvement with childcare. The patient can try to plan her working time to accommodate the days she will be less productive because of PMS. The nurse encourages the patient to use exercise, meditation, imagery, and creative activities to reduce stress. The nurse also encourages the patient to take medications as prescribed and pro-
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vides instructions about the desired effects of the medications. Enrolling in a PMS group that meets to discuss problems may help the patient learn that others recognize and understand what she is experiencing. If the patient has severe symptoms of PMS or premenstrual dysphoric disorder, the nurse assesses her for suicidal, uncontrollable, and violent behavior. Any suggestions of suicidal tendencies must be evaluated by psychiatric consultation immediately. Uncontrollable behavior may lead to violence toward family members. If abuse of children or other members of the patient’s family is suspected, reporting protocols are implemented and followed. Referral is made for immediate psychiatric or psychological care and counseling.
DYSMENORRHEA Primary dysmenorrhea is painful menstruation, with no identifiable pelvic pathology. It occurs at the time of menarche or shortly thereafter. It is characterized by crampy pain that begins before or shortly after the onset of menstrual flow and continues for 48 to 72 hours. Pelvic examination findings are normal. Dysmenorrhea is thought to result from excessive production of prostaglandins, which causes painful contraction of the uterus and arteriolar vasospasm. Psychological factors, such as anxiety and tension, may also contribute to dysmenorrhea. As women grow older, dysmenorrhea often decreases and frequently completely resolves after childbirth. In secondary dysmenorrhea, pelvic pathology such as endometriosis, tumor, or pelvic inflammatory disease (PID) exists. Patients with secondary dysmenorrhea frequently have pain that occurs several days before menses, with ovulation, and occasionally with intercourse.
Assessment and Diagnostic Findings A complete pelvic examination is performed to rule out possible abnormalities, such as strictures of the cervix or vagina, an imperforate hymen, or other conditions, such as endometriosis, PID, adenomyosis, and fibroid uterus. A laparoscopy is usually required to identify organic causes.
Management In primary dysmenorrhea, the reason for the discomfort is explained, and the patient is assured that menstruation is a normal function of the reproductive system. If the patient is young and accompanied by her mother, the mother may also need reassurance. Many young women expect to have painful periods if their mothers did. The discomfort of cramps can be treated once anxiety and concern over its cause are dispelled by adequate explanation. Symptoms usually subside with appropriate medication. Aspirin, a mild prostaglandin inhibitor, may be taken at recommended doses every 4 hours. Other useful prostaglandin antagonists include NSAIDs such as ibuprofen (Motrin), naproxen (Aleve, Anaprox, Naprosyn), and mefenamic acid (Ponstel). Rofecoxib (Vioxx), a COX-2 inhibitor, may also be used. If one medication does not provide relief, another may be recommended. Usually these medications are well tolerated, but some women experience gastrointestinal side effects. Contraindications include allergy, peptic ulcer history, sensitivity to aspirin-like medications, asthma, and pregnancy. Low-dose oral contraceptives provide relief in more than 90% of patients and are indicated in
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women with dysmenorrhea who are sexually active but do not desire a pregnancy. Continuous low-level local heat has recently been found to be effective in treating primary dysmenorrhea and may be as effective as medication (Akin, Weingand, Hengehold et al., 2001). The mechanism is not clear, but heat may counteract the activity of hormones that cause the uterus to contract. Heat is a vasodilator that increases blood flow and may counteract constriction and muscle contraction. Heat therapy and medication have been found to work well in combination. The patient is encouraged to continue her usual activities and to increase physical exercise if possible, as this seems to relieve discomfort for some women. Taking analgesic agents before cramps start, in anticipation of discomfort, is advised. Management of secondary dysmenorrhea is directed at diagnosis and treatment of the underlying cause (eg, endometriosis or PID). The same analgesic agents used for primary dysmenorrhea may be part of the management of secondary dysmenorrhea due to endometriosis.
AMENORRHEA Amenorrhea (absence of menstrual flow) is a symptom of a variety of disorders and dysfunctions. Primary amenorrhea (delayed menarche) refers to the situation in which a young woman older than 16 has not begun to menstruate but otherwise shows evidence of sexual maturation, or when a young woman has not begun to menstruate and has not begun to show development of secondary sex characteristics by 14 years of age. Amenorrhea may be of considerable concern but is usually due to minor variations in body build, heredity, environment, and physical, mental, and emotional development. The nurse allows the patient to express her concerns and anxiety about this problem, because the patient may feel that she is different from her peers. A complete physical examination, careful health history, and simple laboratory tests help to rule out possible causes, such as physiologic disorders, metabolic or endocrine difficulties, and systemic diseases. Treatment is directed toward correcting any abnormalities. Secondary amenorrhea (an absence of menses for three cycles or 6 months after a normal menarche) may be caused by pregnancy, tension, emotional upset, or stress. In an adolescent, secondary amenorrhea is usually caused by minor emotional upset related to being away from home, attending college, tension due to schoolwork, or interpersonal problems. The second most common cause, however, is pregnancy, so a pregnancy test is almost always indicated. Secondary nutritional disturbances may also be factors. Obesity can result in anovulation and subsequent amenorrhea. Eating disorders, such as anorexia and bulimia, are characterized by lack of menses because the decrease in body fat and caloric intake affects hormonal function. Competitive female athletes typically experience amenorrhea and are frequently placed on HRT to prevent bone loss related to low estrogen levels. On occasion, a pituitary or thyroid dysfunction may cause amenorrhea. These dysfunctions can be treated successfully by treatment of the underlying endocrine disorder. Infrequent periods (oligomenorrhea) may be related to thyroid disorders, polycystic ovarian syndrome, or premature ovarian failure. Again, evaluation by a primary health care provider is necessary.
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Unit 10
REPRODUCTIVE FUNCTION
ABNORMAL UTERINE BLEEDING Dysfunctional uterine bleeding is abnormal bleeding that does not have a known organic cause. This can occur at any age but is most common at opposite ends of the reproductive life span. Dysfunctional uterine bleeding is defined as irregular, painless bleeding of endometrial origin that may be excessive, prolonged, or without pattern. It is usually secondary to anovulation (lack of ovulation) and is common in adolescents and women approaching menopause. Adolescents account for many cases of abnormal uterine bleeding since they often do not ovulate as their pituitary-ovarian axis matures. Perimenopausal women also experience this condition due to irregular ovulation because of their decreasing ovarian hormone production. The remaining causes are often related to cysts, obesity, or hypothalamic dysfunction. Abnormal or unusual vaginal bleeding that is atypical in time or amount must be evaluated because it may be a manifestation of a major, life-threatening disorder. Physical examination is performed and the patient is evaluated for conditions such as pregnancy, neoplasm, infection, anatomic abnormalities, endocrine disorders, trauma, blood dyscrasias, platelet dysfunction, and hypothalamic disorders. Women of any age require evaluation for a specific cause of uterine bleeding. Pregnancy testing and hormonal evaluation are usually part of the initial assessment. Treatment usually consists of hormones or oral contraceptives.
Menorrhagia Menorrhagia is defined as prolonged or excessive bleeding at the time of the regular menstrual flow. In early life the cause is usually related to endocrine disturbance, whereas in later life it usually results from inflammatory disturbances, tumors of the uterus, or hormonal imbalance. Emotional disturbances may also affect bleeding. The nurse encourages a woman with menorrhagia to see her primary health care provider and to describe the amount of bleeding by pad count and saturation (ie, absorbency of perineal pad or tampon and number saturated hourly). Persistent heavy bleeding can result in anemia.
Metrorrhagia Metrorrhagia (vaginal bleeding between regular menstrual periods) is probably the most significant form of menstrual dysfunction because it may signal cancer, benign tumors of the uterus, or other gynecologic problems. This condition warrants early diagnosis and treatment. Although bleeding between menstrual periods by a woman taking oral contraceptives is usually not serious, irregular bleeding by a woman taking HRT should be evaluated. Menometrorrhagia is heavy vaginal bleeding between and during periods and requires evaluation.
Postmenopausal Bleeding Bleeding 1 year after menses cease at menopause must be investigated, and a malignant condition must be considered until proved otherwise. An endometrial biopsy or a D & C is indicated. A vaginal ultrasound can also be used in postmenopausal bleeding to measure the thickness of the endometrial lining. The uterine lining in postmenopausal women should be thin because of low estrogen levels. A lining thicker than 5 mm usually warrants evaluation by endometrial biopsy.
Management of Normal and Altered Female Reproductive Function DYSPAREUNIA Dyspareunia (difficult or painful intercourse) is increasing in incidence and can be superficial, deep, primary, or secondary. This problem can be embarrassing for women to discuss because they may believe that it is their problem if their partner is not experiencing discomfort. Dyspareunia may occur at the beginning of, during, or after intercourse and may be related to injury during childbirth, lack of lubrication, a history of incest, sexual abuse, or assault, endometriosis, pelvic infection, vaginal atrophy with menopause, gastrointestinal disorders, fibroids, urinary tract infection, STDs, or vulvodynia (vulvar pain that affects women of all ages without any discernible physical cause). Because dyspareunia is often due to lack of vaginal lubrication, use of vaginal lubricants can be suggested. Depending on the cause of dyspareunia, antidepressants may be prescribed in selected patients, and surgery to expand or repair the vaginal opening is occasionally needed.
CONTRACEPTION Each year, more than half of the pregnancies in the United States are unintended (Centers for Disease Control and Prevention, 1999). Although unintended pregnancies occur in women of all ages, incomes, and racial and ethnic groups, the highest rates occur among adolescents, lower-income women, and AfricanAmerican women (U.S. Surgeon General, 2001). Adolescents are more likely to experience pregnancy complications and are more prone to have low-birthweight babies. Teen mothers are less likely to obtain a high school diploma and are more likely to live in poverty. Of women undergoing abortions, many did not use contraception in the month they became pregnant, while others never use any method. It seems that women often fail to use effective methods consistently or at all. Nurses can assist with information and support. Women sometimes fear that they will get cancer and fear other risks from contraception. Women often report using their contraceptive method inconsistently, which makes all methods less effective. Many women who are sexually active or who are considering becoming sexually active can benefit from learning about contraception. Fewer unwanted pregnancies may reduce the number of abortions, abused children, stressed families, and infant mortality and morbidity. It is important that women receive unbiased and nonjudgmental information, understand the benefits and risks of each method, learn about alternatives and how to use them, and receive positive reinforcement and acceptance of their choice. Nurses involved in helping patients make contraceptive choices need to listen, educate, spend time answering questions, and assist patients in choosing the method they prefer. Methods and practices to prevent unwanted or unplanned pregnancies and births are described in subsequent sections of this chapter.
Abstinence Abstinence, or celibacy, is the only completely effective means of preventing pregnancy. Abstinence may not be a desired or available option for many women because of cultural expectations and their own and their partner’s values and sexual needs.
Chapter 46
Assessment and Management of Female Physiologic Processes
Sterilization After abstinence, sterilization by bilateral tubal occlusion or vasectomy is the most effective means of contraception. Both procedures must be considered permanent because neither is easily reversible. Women and men who choose these methods should be certain that they have completed their childbearing, no matter how the circumstances in their life may change. Often, decisions are made that may be regretted later. Some gynecologists suggest a waiting period to ensure that the patient is certain about a potentially irreversible decision. See Chapter 49 for a discussion of vasectomy (male sterilization). TUBAL LIGATION Female sterilization by tubal ligation is one of the most common operations performed on women. More than 600,000 tubal ligations are performed in the United States every year (Jamieson, Hillis, Duerr et al., 2000). Tubal ligation is usually performed as a same-day surgical procedure. The procedure is carried out by laparoscopy, with the patient receiving a general or local anesthetic. The laparoscope, a small periscope-like optical instrument, is inserted through a small umbilical incision. Carbon dioxide is introduced to lift other abdominal organs away from the tubal area. The fallopian tubes are visualized and may be coagulated, sutured (Pomeroy procedure), or ligated with a rubber band or a spring clip, thereby disrupting their patency. Many sterilizations are performed with bipolar coagulation. Silicone bands and spring clips are also being used. Spring clips have the highest rate of pregnancy following sterilization. A new procedure, selective tubal occlusion procedure, uses a 0.6-inch metal coil or spring that is inserted into the fallopian tubes through the cervix, thus avoiding the need for laparoscopy or a surgical incision (Association of Reproductive Health Professionals, 2002). This method works by inducing obstruction of the tubes by scar tissue. Despite a very high rate of effectiveness, any woman who has undergone tubal ligation but misses a period should be tested for pregnancy because ectopic and intrauterine pregnancies, although rare, may occur. Ovulation and menstruation are not affected by sterilization, although some women report heavier menstrual
Chart 46-11
bleeding and more cramping after tubal ligation. Vasectomy and laparoscopic tubal ligation are compared in Chart 46-11. Before undergoing tubal ligation, the patient should be informed that an IUD, if present, will be removed. If the patient is taking oral contraceptives, she usually continues them up to the time of the procedure. Postoperatively, women may experience abdominal or shoulder discomfort for a few days, related to the carbon dioxide gas and the manipulation of organs. The woman is instructed to report heavy bleeding, fever, or pain that persists or increases. The patient should avoid intercourse, strenuous exercise, and lifting for 2 weeks. Risks of the procedure are minimal and are more often related to the anesthesia than to the surgery itself. Risk is increased in women with diabetes, previous abdominal or pelvic surgery, or obesity.
Oral Contraceptives Oral contraceptive preparations of synthetic estrogen (estradiol) and progesterone (desogestrel, ethynodiol diacetate, levonorgestrel, norethindrone, norethindrone acetate or norgestrel) are currently used by many women. They block ovarian stimulation by preventing the release of FSH from the anterior pituitary gland. In the absence of FSH, a follicle does not ripen, and ovulation does not occur. This is the mechanism of action of oral contraceptives. Progestins (synthetic forms of progesterone) suppress the LH surge, prevent ovulation, and also render the cervical mucus impenetrable to sperm. Synthetic estrogens and progestin, found in the many oral contraceptive variations available, differ in androgenic activity (Chart 46-12). BENEFITS AND RISKS In general, no definite long-term undesirable effects have been observed with prolonged oral contraceptive use. Resumption of normal menses is delayed 2 to 3 months in about 20% of oral contraceptive users. Venous thromboembolism has occurred with use of oral contraceptives, but it occurs less now than years ago, when estrogen concentrations in oral contraceptives were higher. Venous thromboembolism is less than half as likely to occur with oral contraceptives than with pregnancy. Desogestrel, a new progestin,
Comparison of Sterilization Methods
Vasectomy Advantages • Highly effective • Relieves the female of the contraceptive burden • Inexpensive in the long run • Permanent • Highly acceptable procedure to most clients • Very safe • Quickly performed Disadvantages • Expensive in the short term • Serious long-term effects suggested (although currently unproved) • Permanent (although reversal is possible, it is expensive and requires a highly technical and major surgery, and its results cannot be guaranteed) • Regret in 5%–10% of patients • No protection against STDs, including HIV • Not effective until sperm remaining in the reproductive system are ejaculated
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Laparoscopic Tubal Sterilization Advantages • Low incidence of complications • Short recovery • Leaves small scar • Quickly performed
Disadvantages • Permanent • Reversal difficult and expensive • Sterilization procedures technically difficult • Requires surgeon, operating room (aseptic conditions), trained assistants, medications, surgical equipment • Expensive at the time performed • If failure, high probability of ectopic pregnancy • No protection against STDs, including HIV
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Unit 10
Chart 46-12
REPRODUCTIVE FUNCTION
• PHARMACOLOGY
Comparison of Oral Contraceptives There are two kinds of oral contraceptives: combined and progestin only. Combined pills consist of an estrogen and a progestin. The result of both types of medications is a lighter-than-normal menstrual flow after the contraceptives are taken for 21 days and then stopped for 7 days. The flow is actually withdrawal bleeding from discontinuing hormones because a normal period occurs only with ovulation. Most women using oral contraceptives take the combination medication. Combined Preparations • Each dose contains estrogen and progestin. • Monophasic preparations supply a constant dose of estrogen and progestin. • Biphasic preparations are available; they contain a constant amount of estrogen, with an increase in the progestin on day 10. • Triphasic preparations are available; they provide varying low doses of estrogen along with progesterone during the 21-day cycle. This variation provides an effective contraceptive that mimics the normal cycle and has enough progesterone to prevent ovulation and spotting. Progestin-Only “Mini” Preparations • Each dose contains progestin only (estrogen is not contained in a progestin-only preparation). • Preparation provides less protection against conception than combined preparations. • About 40% of women taking progestin only have ovulatory cycles. • Progestin only is useful for women who have had estrogen-related side effects on combination pills (eg, headaches, hypertension, leg pain, chloasma or skin discoloration, weight gain, or nausea). • Progestin-only preparations are useful for lactating women who need a hormonal contraceptive method.
may be slightly more likely to be associated with venous thromboembolism, but the risk is still very low. Gallbladder problems (eg, cholestasis) may occur. Fetal anomalies do not appear to be a concern, and normal reproductive tract function and fertility are restored after oral contraceptive use is discontinued. However, most health care providers recommend that women use a barrier contraceptive method for 1 to 2 months after stopping the pill before becoming pregnant so that the accurate date of the last menstrual period is available to date the pregnancy. Some of the benefits of using oral contraceptives include a reduction in the incidence of benign breast disease, improvement in acne, reduced risk of uterine and ovarian cancers, anemia, and pelvic infection.
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NURSING ALERT Patients need to be aware that oral contraceptives protect them from pregnancy but not from STDs or HIV infection. In addition, sex with multiple partners or sex without a condom may also result in chlamydial and other infections, including HIV infection.
A few patients experience adverse reactions when using oral contraceptives. These include nausea, depression, headache, weight gain, leg cramps, and breast soreness. Usually, these symptoms subside after 3 or 4 months. Because such symptoms are sometimes related to sodium and water retention caused by estrogen, a smaller dose of the hormone or a different hormonal combination may alleviate the problem. Many patients experi-
ence spotting in the first month taking the pill or if they take it irregularly, so they need to be reassured and advised to take a pill every 24 hours, as prescribed. Chart 46-13 describes the benefits and risks of oral contraceptive use. CONTRAINDICATIONS Absolute contraindications include current or past thromboembolic disorder, cerebrovascular disease, or artery disease; known or suspected breast cancer; known or suspected current or past estrogen-dependent neoplasia; pregnancy; current or past benign or malignant liver tumor; impaired liver function; congenital hyperlipidemia; and undiagnosed abnormal vaginal bleeding. Relative contraindications include hypertension, bile-induced jaundice, acute phase of mononucleosis, and sickle cell disease. Women older than 35 who smoke are at risk for cardiac problems and should not use oral contraceptives. Occasionally, neuroocular complications arise, but a cause-and-effect relationship has not been established. If visual disturbances occur, oral contraceptives should be discontinued (Chart 46-14). Some gynecologists allow patients with migraine headaches to take oral contraceptives if the headaches do not worsen with use or so long as the patient has no neurologic symptoms. (A young woman who has blurred vision with a migraine will probably be discouraged from taking oral contraceptives.) Diabetes is also problematic, although some diabetes specialists allow their patients to use oral contraceptives with careful glucose monitoring. Leiomyomas (fibroid tumors) of the uterus can enlarge with oral contraceptive use. Patients with this condition are advised and monitored carefully; if fibroids enlarge, they are advised to discontinue oral contraceptives and choose another contraceptive method.
Injectable Contraceptives DEPO-PROVERA An intramuscular injection of Depo-Provera, a long-acting progestin, every 3 months inhibits ovulation and provides a reliable
Chart 46-13
• PHARMACOLOGY
Benefits and Risks of Oral Contraceptives Benefits • Decreased cramps and bleeding • Regular bleeding cycle • Decreased incidence of anemia • Decrease in acne with some formulations • Protection from uterine and ovarian cancer • Decreased incidence of ectopic pregnancy • Protection from benign breast disease • Decreased incidence of pelvic infection Risks • Rare in healthy women • Bothersome side effects (eg, breakthrough bleeding, breast tenderness) • Nausea, weight gain, mood changes • Small increased risk of developing blood clots, stroke, or heart attack, related more to smoking than to oral contraceptive use alone • Possible increased incidence of benign liver tumors and gallbladder problems • No protection from STDs (possible increased risk with unsafe sex)
Chapter 46
Chart 46-14
Assessment and Management of Female Physiologic Processes
• PATIENT EDUCATION
Using Oral Contraceptives • • • •
Use condoms to protect against sexually transmitted diseases. Take pill at exactly the same time every day. Stop smoking or cut down on smoking. Report the following symptoms immediately: A —abdominal pains C —chest pains H—headaches E —eye problems (blurred vision or spots) S —severe leg pains
and convenient contraceptive method. It can be used by lactating women and those with hypertension, liver disease, migraine headaches, heart disease, and hemoglobinopathies. Women who use this method must be prepared for irregular or no bleeding. With continued use, irregular bleeding episodes and spotting decrease, and amenorrhea usually occurs. Advantages include reduction of menorrhagia, dysmenorrhea, and anemia. It may reduce the risk of pelvic infection and has been associated with improvement in hematologic status in women with anemia due to heavy menstrual bleeding and women with sickle cell disease; it has also been associated with a reduced frequency of seizures in women with seizure disorders. It also reduces the risk of endometrial cancer (ACOG Technical Bulletin #198, 1995). Potential disadvantages include irregular menstrual bleeding, bloating, headaches, hair loss, decreased sex drive, and weight loss or weight gain. Fertility may be delayed when women discontinue this method; therefore, other methods of contraception may be more appropriate for the woman who wishes to conceive within a year of discontinuing contraception. Depo-Provera is contraindicated in women who are pregnant and those who have abnormal vaginal bleeding of unknown cause, breast or pelvic cancer, or sensitivity to synthetic progestin. The long-term effects on the infant of a nursing mother who uses DepoProvera are unknown but are thought to be negligible. DepoProvera does not protect against STDs. Bone density is temporarily decreased while using this method, but this does not seem to be a long-term health risk. LUNELLE Lunelle, a contraceptive that is a combination of medroxyprogesterone (progestin) and estradiol (estrogen), has been shown to be very effective at preventing pregnancy in clinical trials. An intramuscular injection is administered every 28 to 30 days. It provides immediate efficacy if given within the first 5 days following the start of a normal menstrual period. Return to ovulation occurs more quickly than with Depo-Provera, usually within 2 to 4 months. The contraindications and cautions are the same as those for oral contraceptives. Effectiveness depends on the woman’s compliance with the regimen. Similar to other nonbarrier contraceptive methods, Lunelle does not protect against HIV infection or other STDs. Light, regular monthly bleeding occurs.
Implant Contraceptive The Norplant system is a reversible, low-dose, progestin-only contraceptive device consisting of several soft Silastic capsules or implants that are inserted under the skin of the woman’s upper
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arm. The implant releases the progestin levonorgestrel over 5 years, thereby inhibiting ovulation. While still FDA-approved, it is anticipated that Norplant will not be available in the future. However, additional implant contraceptives are expected to become available in the near future. Contraindications to using these systems are acute liver disease or liver tumors, pregnancy, unexplained vaginal bleeding, breast cancer, and a history of thrombophlebitis or pulmonary embolism. Common side effects include irregular bleeding, weight gain, acne, and hair growth or hair loss. If patients are aware of these disadvantages and side effects, they are more likely to tolerate the implant and continue using it. The patient should report headaches or visual symptoms to a health care provider because rare instances of idiopathic intracranial hypertension have been associated with the implant. Papilledema must be ruled out if headaches occur. Insertion, minor surgery that is relatively painless, is performed under aseptic conditions in an outpatient setting such as an office or clinic. A small incision is made in the inner upper arm after the patient receives a local anesthetic. The capsule or capsules are inserted within the first 7 days of the menstrual cycle to avoid the possibility of a preexisting pregnancy. The contraceptive effect occurs within 24 hours and lasts for 5 years. Insertion usually takes about 15 minutes. Although the implants can be removed at any time, it can be a more difficult and lengthy procedure because over time tissue encapsulates the implants. Women who have regular bleeding with an implant method are at higher risk for pregnancy and should be counseled to have a pregnancy test if the regular bleeding stops.
New Hormonal Methods of Contraception Two new hormonal methods of contraception are Ortho Evra and NuvaRing. Ortho Evra is a thin, beige, matchbook-sized square that releases an estrogen and a progestin continuously. It is changed every week for 3 weeks. The fourth week is patch-free, producing withdrawal bleeding. The effectiveness of Ortho Evra is comparable to that of oral contraceptives. Its risks are similar to those of oral contraceptives and include an increased risk of blood clots. The patch may be applied to the torso, chest, arms, or thighs; it should not be applied to the breasts. NuvaRing is a vaginal ring that is inserted in the vaginal for 3 weeks and then removed, resulting in withdrawal bleeding. It is as effective as oral contraceptives and has the same risks. It is flexible, does not require sizing or fitting, and is effective when placed anywhere in the vagina. Although both of these contraceptive methods increase the options for women, neither protects against STDs. Women using these methods should be instructed not to smoke. Chart 46-15 lists hormonal methods of birth control approved by the FDA.
Intrauterine Device An IUD is a small plastic device, usually T-shaped, that is inserted into the uterine cavity to prevent pregnancy. A string attached to the IUD is visible and palpable at the cervical os. An IUD prevents conception by causing a local inflammatory reaction that is toxic to spermatozoa and blastocysts, thus preventing fertilization. The IUD does not work by causing abortion. Paraguard, a copper-bearing IUD, is effective for 10 years. Copper has an antispermatic effect. The Levonorgestrel Intrauterine System (LNG-IUS; Mirena) is an IUD that releases levonorgestrel, a synthetic progestin used in oral contraceptives, and has been found to reduce heavy bleeding. Limited studies
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Chart 46-15
Unit 10
REPRODUCTIVE FUNCTION
FDA-Approved Hormonal Methods of Birth Control
Combination Combination oral contraceptive pills Combination emergency contraception (Preven) Once-a-month injection (Lunelle) Vaginal ring (NuvaRing) Transdermal patch (Ortho Evra) Progestin-Only Methods Progestin-only pills or minipills (Norgestrel) Progestin-only emergency contraception (Plan B) Once-every-3-months injection (DepoProvera) Levonorgestrel-releasing intrauterine system (Mirena) Implants (Norplant)
show that IUDs may prevent the need for hysterectomy in some women by reducing bleeding, may be an adjunct in HRT, may protect women from endometrial cancer, and may prevent cervical cancer. The IUD method is effective over a long time, appears to have no systemic effects, and reduces the possibility of patient error. This reversible method of birth control is as effective as oral contraceptives and more effective than barrier methods. Disadvantages include possible excessive bleeding, cramps, and backaches and a slight risk of tubal pregnancy, pelvic infection, displacement of the device, and, rarely, perforation of the cervix and uterus. If a pregnancy occurs with an IUD in place, the device is removed immediately to avoid infection. Spontaneous abortion (miscarriage) may occur on removal. An IUD is not usually used in women who have not had children because the nulliparous uterus may be too small to tolerate it. Women with multiple partners, women with heavy or crampy periods, or those with a history of ectopic pregnancy or pelvic infection are encouraged to use other methods. Some clinicians test for chlamydia and gonorrhea prior to insertion to prevent PID.
more than 6 hours have passed before intercourse occurs and before each act of intercourse. On removal, the diaphragm is cleansed thoroughly with mild soap and water, rinsed, and dried before it is stored in its original container. Disadvantages include allergic reactions in those who are sensitive to latex and an increased incidence of urinary tract infections. Toxic shock syndrome has been reported in some diaphragm users.
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NURSING ALERT The nurse must assess the woman for possible latex allergy because use of latex barrier methods may cause severe allergic reactions, including anaphylaxis, in patients with latex allergy.
CERVICAL CAP The cervical cap is much smaller (22 to 35 mm) than the diaphragm and covers only the cervix; it is used with a spermicide. If a woman can feel her cervix, she can usually learn to use a cervical cap. The chief advantage is that the cap may be left in place for 2 days. Although convenient to use, the cervical cap may cause cervical irritation; therefore, before fitting a cap, most clinicians obtain a Pap smear and repeat the smear after 3 months. The cap can stay in place for 48 hours and does not require additional spermicide for repeated acts of intercourse. FEMALE CONDOM The female condom was developed to provide women with protection from STDs and HIV as well as pregnancy. The female condom (Reality) consists of a cylinder of polyurethane enclosed at one end by a closed ring that covers the cervix and at the other end by an open ring that covers the perineum (Fig. 46-8). Advantages include some degree of protection from STDs (HPV, herpes simplex
Upper ring
Mechanical Barriers DIAPHRAGM The diaphragm is an effective contraceptive device that consists of a round, flexible spring (50 to 90 mm wide) covered with a dome-like latex rubber cup. A spermicidal (contraceptive) jelly or cream is used to coat the concave side of the diaphragm before it is inserted deep into the vagina, covering the cervix. The diaphragm is a spermicide holder; the spermicide inhibits spermatozoa from entering the cervical canal. The diaphragm is not felt by the user or her partner when properly fitted and inserted. Because women vary in size, the diaphragm must be sized and fitted by an experienced clinician. The woman is instructed in using and caring for the device. A return demonstration ensures that the woman can insert the diaphragm correctly and that it covers the cervix. Each time that the woman uses the diaphragm, she should examine it carefully. By holding it up to a bright light, she can ensure that there are no pinpoint holes, cracks, or tears in the diaphragm. Spermicidal jelly or cream is applied, and the diaphragm is then positioned to cover the cervix completely. The diaphragm should remain in place at least 6 hours (but no more than 12 hours) after coitus. Additional spermicide is applied if
Female condom
FIGURE 46-8 place.
Female condom. The upper ring keeps the condom in
Chapter 46
Assessment and Management of Female Physiologic Processes
virus, and HIV). Disadvantages include the inability to use the female condom with some coital positions (ie, standing). SPERMICIDES Spermicides are available over the counter as foams, gels, and inserts and on condoms. Spermicides are effective, relatively inexpensive chemical contraceptives when used with condoms. When used alone, spermicide is better than no contraception at all; it can be used without a partner’s cooperation and may provide protection from gonorrhea and chlamydia. Burning, a rash, or irritation can develop in either partner and is usually temporary. Changing to another brand of spermicide often alleviates the problem. Spermicides are made from nonoxynol-9 or octoxynol. Nonoxynol-9 has been found to be associated with minute tears in vaginal tissue with frequent use, possibly increasing the possibility of contracting HIV from an infected partner (Stephenson, 2000). It also may increase the risk of latex allergy when used with a condom by leaching out a natural rubber protein from the latex (Greydanus, Patel & Rimsza, 2001). MALE CONDOM The male condom is an impermeable, snug-fitting cover applied to the erect penis before it enters the vaginal canal. The tip of the condom is pinched while being applied to leave space for ejaculate. If no space is left, ejaculation may cause a tear or hole in the condom and reduce its effectiveness. The penis, with the condom held in place, is removed from the vagina while still erect to prevent the ejaculate from leaking. The condom is an effective method when used with contraceptive foam. The latex condom also creates a barrier against transmission of STDs, especially gonorrhea, chlamydial infection, and HIV. Natural condoms (those made from animal tissue), however, do not protect against HIV infection. The nurse needs to reassure women that they have a right to insist on their male partner using a condom and a right to refuse sex without condoms, although women in abusive relationships may increase their risk for abuse by doing so. Some women are buying and carrying condoms with them to be certain that one is available. Nurses should be familiar and comfortable with instructions about using a condom because many women need to know about this way of protecting themselves from HIV and other STDs. During patient teaching about barrier methods of contraception, nurses need to consider the possibility of latex allergy for themselves and their patients. Contact dermatitis is often the first symptom of latex allergy. Swelling and itching can also occur. Possible warning signs of latex allergy include oral itching after blowing up a balloon or eating kiwis, bananas, pineapples, passion fruits, avocados, or chestnuts. Because many contraceptives are made of latex, patients who experience burning or itching while using a latex contraceptive are instructed to see their primary health care provider. Alternatives to latex condoms may include the female (Reality) and male (Avanti) condoms made of polyurethane. Condoms do not provide complete protection from STDs, as the HPV virus may be transmitted by skin-to-skin contact. Other STDs may be transmitted if any abraded skin is exposed to body fluids. This information should be included in patient teaching.
Coitus Interruptus Coitus interruptus (removing the penis from the vagina before ejaculation) requires careful control by the male. Although it is a frequently used method of preventing pregnancy, it is considered an unreliable method of contraception.
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Rhythm and Natural Methods Natural family planning is any method of conception regulation that is based on awareness of signs and symptoms of fertility during a menstrual cycle. The advantages of natural contraceptive methods include the following: (1) they are not hazardous to health, (2) they are inexpensive, and (3) they are approved by some religions. The disadvantage is that they require discipline by the couple, who must monitor the menstrual cycle and abstain from sex during the fertile phase. In addition, the rhythm method of contraception can be difficult to use because it relies on the woman determining her time of ovulation and on avoiding intercourse during the fertile period. The fertile phase (which requires sexual abstinence) is estimated to occur about 14 days before menstruation, although it may occur between the 10th and 17th days. Spermatozoa can fertilize an ovum up to 72 hours after intercourse, and the ovum can be fertilized for 24 hours after leaving the ovary. The pregnancy rate with the rhythm method is about 40% yearly. Women who carefully determine their “safe period,” based on a precise recording of menstrual dates for at least 1 year, and who follow a carefully worked-out formula may achieve very effective protection. A long abstinence period during each cycle is required. These prerequisites require more time and control than many couples have. Changes in cervical mucus and basal body temperature due to hormonal changes related to ovulation form the scientific basis for the symptothermal method of ovulatory timing. Courses in natural family planning are offered at many Catholic hospitals and some family planning clinics. Ovulation detection methods (eg, Ovulindex) are available in most pharmacies. The presence of the enzyme guaiacol peroxidase in cervical mucus signals ovulation 6 days beforehand and also affects mucosal viscosity. Test kits are available over the counter and are easy to use and reliable, but they can be expensive. Ovulation prediction kits are more effective for planning conception than for avoiding it.
Emergency Contraception DOSE OF ESTROGEN/PROGESTIN A properly timed, adequate dose of estrogen or estrogen and a progestin after intercourse without birth control, or when a method has failed, can prevent pregnancy by inhibiting or delaying ovulation. This method does not interrupt an established pregnancy. Nurses should be aware of this option and the indications for its use. This method obviously is not suitable for longterm contraception because it is not as effective as daily oral contraceptives or other reliable methods used regularly. However, it is valuable in emergency situations such as rape, a defective or torn condom or diaphragm, or other situations that may present the possibility of unwanted conception. It can be prescribed as Preven (estrogen/progestin) or Plan B (progestin) packages of emergency contraception with patient literature or it can be prescribed as a specific number of contraceptive pills, depending on the medication and dose used. Usually, a small dose of oral contraceptives (ie, levonorgestrel and ethinyl estradiol) is given and repeated in 12 hours (called the Yuzpe method after the gynecologist who developed the method). This method must be used not more than 72 hours after intercourse. Nausea, a common side effect, can be minimized by taking the medication with meals and with an antiemetic medication. Other side effects, such as breast soreness and irregular bleeding, may occur but are transient. Any patient using this method should
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be advised of the 1.6% failure rate and counseled about other contraceptive methods. Emergency contraception is related to luteal phase dysfunction, producing an endometrium that is out of phase. There are no known contraindications to the use of this method (Morris & Young, 2000). The nurse reviews with the patient instructions for taking the pills based on the medication regimen prescribed. If the woman is breastfeeding, a progestin-only formulation is prescribed. To avoid exposing the infant to synthetic hormones through breast milk, she can manually express milk and bottle-feed for 24 hours after treatment. The woman’s next menstrual period may begin a few days earlier or a few days later than expected, and she needs to be informed of this. The patient must return for a pregnancy test if she has not had a menstrual period in 3 weeks and should be offered another visit to provide a regular method of contraception if she does not have one currently. This medication may also be dispensed by pharmacists without a prescription in some states. All women need to be aware of this option and how to obtain it. Nurses can educate and inform women about it to reduce unwanted pregnancies and abortions. See the list of resources at the end of this chapter for more information on this method. POSTCOITAL IUD INSERTION Postcoital IUD insertion, another form of emergency contraception, involves insertion of a copper-bearing IUD within 5 days of exposure in women who want this method of contraception; however, it may be inappropriate for some women or if other contraindications exist. The mechanism of action is unknown, but it is thought that the IUD interferes with fertilization (Morris & Young, 2000). The patient may experience discomfort on insertion and heavier menstrual periods and increased cramping. Contraindications include a confirmed or suspected pregnancy or any contraindication to regular copper IUD use. The patient must be informed that there is a risk that insertion of an IUD may disrupt a pregnancy that is already present. NURSING MANAGEMENT Patients who use emergency contraception may be anxious, embarrassed, and lacking information about birth control. Nurses must be supportive and nonjudgmental and provide facts and appropriate patient teaching. If a patient repeatedly uses this method of birth control, she should be informed that the failure rate with this method is higher than with a regularly used method. A toll-free telephone information service (1-888-Not-2Late) operates 24 hours a day in English and Spanish and provides information and referrals to health care providers.
ABORTION Interruption of pregnancy or expulsion of the product of conception before the fetus is viable is called abortion. The fetus is generally considered to be viable any time after the fifth to sixth month of gestation. The term “premature labor” is used when a woman experiences labor after this point in the pregnancy.
Spontaneous Abortion It is estimated that 1 of every 5 to 10 conceptions results in spontaneous abortion. Most of these occur because an abnormality in the fetus makes survival impossible. Other causes may include
systemic diseases, hormonal imbalance, or anatomic abnormalities. If a pregnant woman experiences bleeding and cramping, a threatened abortion is diagnosed because an actual abortion is usually imminent. Spontaneous abortion occurs most commonly in the second or third month of gestation. There are various kinds of spontaneous abortion, depending on the nature of the process (threatened, inevitable, incomplete, or complete). In a threatened abortion, the cervix does not dilate. With bed rest and conservative treatment, the abortion may be prevented. If it cannot, an abortion is imminent. If only some of the tissue is passed, the abortion is referred to as incomplete. If the fetus and all related tissue are spontaneously evacuated, the abortion is complete. HABITUAL ABORTION Habitual or recurrent abortion is defined as successive, repeated, spontaneous abortions of unknown cause. As many as 60% of abortions may result from chromosomal anomalies. After two consecutive abortions, patients are referred for genetic counseling and testing, and other possible causes are explored. If bleeding occurs in these patients, conservative measures, such as bed rest and administering progesterone to support the endometrium, are tried in an attempt to save the pregnancy. Supportive counseling is crucial in this stressful condition. Bed rest, sexual abstinence, a light diet, and no straining on defecation are recommended in an effort to prevent spontaneous abortion. If infection is suspected, antibiotics may be prescribed. In the condition known as incompetent or dysfunctional cervix, the cervix dilates painlessly in the second trimester of pregnancy, often resulting in a spontaneous abortion. In such cases, a surgical procedure called cervical cerclage may be used to prevent the cervix from dilating prematurely. The procedure involves placing a purse-string suture around the cervix at the level of the internal os. Bed rest is usually advised to keep the weight of the uterus off the cervix. The patient and her health care providers must be informed that such a suture is in place in this high-risk pregnancy. About 2 to 3 weeks before term or the onset of labor, the suture is cut. Delivery is usually by cesarean section. MEDICAL MANAGEMENT After a spontaneous abortion, all tissue passed vaginally is saved for examination. The patient and all personnel caring for her are alerted to save any discharged material. In the rare case of heavy bleeding, the patient may require blood component transfusions and fluid replacement. An estimate of the bleeding volume can be determined by recording the number of perineal pads and the degree of saturation over 24 hours. When an incomplete abortion occurs, oxytocin may be prescribed to cause uterine contractions before dilation and evacuation (D & E) or uterine suctioning. NURSING MANAGEMENT Because patients experience loss and anxiety, emotional support and understanding are important aspects of nursing care. The response of the woman who desperately wants a baby is very different from that of the woman who does not want to be pregnant but may be frightened by the possible consequences of an abortion. The nurse must be aware that the woman having a spontaneous abortion often experiences a grieving period. The grieving
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may be delayed and may cause other problems until resolved. The many reasons for a delayed grief reaction include the following: friends may not have known the woman was pregnant; the woman may not have seen the lost fetus and can only imagine the gender, size, and characteristics of the child who never developed; there is usually no burial service; and those who know about the loss (family, friends, caregivers) may encourage denial by rarely talking about the loss or by discouraging the woman from crying. Providing opportunities for the patient to talk and express her emotions helps and also provides clues for the nurse in planning more specific care. Those closest to the woman are encouraged to give emotional support and to allow her to talk and freely express her grief. Unresolved grief may manifest itself in persistent vivid memories of the events surrounding the loss, persistent sadness or anger, and episodes of overwhelming emotion when recalling the loss. Dysfunctional grief may require the assistance of a skilled therapist.
Elective Abortion A voluntary induced termination of pregnancy is called an elective abortion and is usually performed by skilled health care providers. In 1973, the U.S. Supreme Court in Roe v. Wade ruled that decisions about abortion reside with a woman and her physician in the first trimester. During the second trimester, the state may regulate practice in the interest of a woman’s health and during the final weeks of pregnancy may choose to protect the life of the fetus, except when necessary to preserve the life or health of the woman.
Chart 46-16
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Legislation has been passed to increase access to abortion clinics and to prevent violence toward those who work in such facilities. The rate of abortion, steady from 1980 to 1990, decreased 15% from 1990 to 1995. Rates since then have been the lowest since 1975 (Zapka, Lemon, Peerson et al., 2001). However, the rate has increased among the following groups of females: unmarried Caucasian girls under age 15, unmarried non-Caucasian girls ages 15 to 19, and married non-Caucasian women ages 20 to 24. The U.S. rates of abortion are among the highest in the industrialized Western world. These numbers point out the need for nurses to provide contraceptive education and counseling. Elective abortions may be carried out in many different ways (Chart 46-16). MEDICAL MANAGEMENT Before the procedure is performed, a nurse or counselor trained in pregnancy counseling explores with the patient her fears, feelings, and options. After the patient’s choice is identified (ie, continuing pregnancy and parenthood; continuing pregnancy followed by adoption; or terminating pregnancy by abortion), a pelvic examination is performed to determine uterine size. Laboratory studies before an abortion must include a pregnancy test to confirm the pregnancy, hematocrit to rule out anemia, Rh determination, and an STD screen. A patient with anemia may need an iron supplement, and an Rh-negative patient may require RhoGAM to prevent isoimmunization. Before the procedure, all patients should be screened for STDs to prevent introducing pathogens upward through the cervix during the procedure.
Types of Elective Abortions
Vacuum Aspiration • The cervix is dilated manually with instrumentation or by laminaria (small suppositories made of seaweed that swells as it absorbs water). • A uterine aspirator is introduced. • Suction is applied, and tissue is removed from the uterus. This is the most common type of termination procedure and is used early in pregnancy, up to 14 weeks. Laminaria may be used to soften and dilate the cervix prior to the procedure. Dilation and Evacuation Cervical dilation with laminaria followed by vacuum aspiration Labor Induction These procedures account for less than 1% of all terminations and generally take place in an inpatient setting. 1. Installation of saline or urea results in uterine contractions. • Although rare, serious complications can occur, including cardiovascular collapse, cerebral edema, pulmonary edema, renal failure, and disseminated intravascular coagulopathy (DIC). 2. Prostaglandins • Prostaglandins are introduced into the amniotic fluid or by vaginal suppository or intramuscular injection in later pregnancy. • Strong uterine contractions begin within 4 hours and usually result in abortion. • Gastrointestinal side effects (eg, nausea, vomiting, diarrhea, and abdominal cramping) and fever can occur. 3. Intravenous oxytocin Used for later abortions for genetic indications. Requires patient to go through labor.
Medical Abortion Mifepristone • Mifepristone (formerly known as RU-486) is a progesterone antagonist that prevents implantation of the ovum. • Administered orally within 10 days of an expected menstrual period, mifepristone produces a medical abortion in most patients. • Combined with a prostaglandin suppository, mifepristone causes abortion in up to 95% of patients. • Prolonged bleeding may occur. Other side effects may include abdominal pain, nausea, vomiting, and diarrhea. This method may not be used in women with adrenal failure, asthma, longterm corticosteroid therapy, an IUD in place, porphyria, or a history of allergy to mifepristone or other prostaglandins. It is less effective when used in pregnancies more than 49 days from the beginning of the last menstrual period. Methotrexate • Methotrexate has also been used to terminate pregnancy because it is a teratogen that is lethal to the fetus. It has been found to have minimal risk and few side effects in the woman. Its low cost may provide an alternative for some women. Misoprostol • Misoprostol is a synthetic prostaglandin analog that produces cervical effacement and uterine contractions. • Inserted vaginally, misoprostol is effective in terminating a pregnancy in about 75% of cases. • When combined with methotrexate or mifepristone, misoprostol’s effectiveness rate is high.
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NURSING MANAGEMENT Patient teaching is an important aspect of care for women who elect to terminate a pregnancy. A woman undergoing elective abortion is informed about what the procedure entails and the expected course after the procedure. The patient is scheduled for a follow-up appointment 2 weeks after the procedure and is instructed in recognizing and reporting signs and symptoms of complications (ie, fever, heavy bleeding, or pain). Available contraceptive methods are reviewed with the patient at this time. Effectiveness depends on the method used and the extent to which the woman and her partner follow the instructions for use. The woman who has used any method of birth control should be assessed for her understanding of the method and its potential side effects and her satisfaction with the method. If the patient was not using contraception, the nurse explains all methods and their benefits and risks and assists the patient in making a contraceptive choice for use after abortion. An increasingly important related teaching issue is the need to use barrier contraceptive devices (ie, condoms) for protection against transmission of STDs and HIV infection. Psychological support is another important aspect of nursing care. Nurses need to be aware that women terminate pregnancies for many reasons. Some women terminate pregnancies because of severe genetic defects. Many women who have been raped or impregnated in incestuous relationships or by an abusive partner elect to terminate their pregnancies. Infertility patients may elect to undergo selective termination if they become pregnant with multiple fetuses. In pregnancies with multiple gestation, adverse outcomes are directly proportional to the number of fetuses in the uterus. Such multifetal reductions are specialized procedures that are stressful and difficult for the parents; therefore, psychological support and understanding are required. The care of women undergoing termination of pregnancy is stressful, and assistance needs to be provided in a safe and nonjudgmental way. Nurses have the right to refuse to participate in a procedure that is against their religious beliefs but are professionally obligated not to impose their beliefs or judgments on their patients.
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NURSING ALERT Some women resort to using unskilled attempts to end a pregnancy. The methods usually include administering large amounts of various toxic agents (effects are toxic, and the uterus is never fully evacuated) or performing a curettage, with the associated risks of uterine rupture, hemorrhage, or infection. If a woman who has had a septic abortion receives proper medical attention early enough and is treated with broad-spectrum antibiotics, the prognosis is excellent. Fluid and blood component replacement may be required before careful attempts are made to evacuate the uterus.
Patients may opt for a type of abortion that ends a pregnancy by using medication rather than surgery. Mifepristone (RU-486, Mifeprex) is used only in early pregnancy (up to 49 days from the last menstrual period). It works by blocking progesterone. Cramping and bleeding similar to a heavy menstrual period will occur. This method requires three visits to a health care provider. The first visit consists of counseling and consent. A sonogram may be used to confirm the pregnancy. Mifepristone will then be administered. The second visit consists of a pelvic examination and possible sonogram to check if the pregnancy has been terminated. A third visit 12 days later is to make sure that the pelvic examination is normal and that the pregnancy has been termi-
nated. If the pregnancy persists, options will be discussed, including surgical abortion (ACOG Practice Bulletin #26, 2001).
Infertility Infertility is defined as a couple’s inability to achieve pregnancy after 1 year of unprotected intercourse. Primary infertility refers to a couple who has never had a child. Secondary infertility means that at least one conception has occurred, but currently the couple cannot achieve a pregnancy. In the United States, infertility is a major medical and social problem, affecting 10% to 15% of the reproductive-age population. In 20%, the infertility is unexplained. The remaining 80% involve medical causes equally distributed between men and women (ACOG Technical Bulletin #125, 2001; Compendium, 2000). Women’s infertility may be related to anovulation, uterine or cervical factors, blocked fallopian tubes, or endometriosis, while men’s infertility is related to sperm quality or sperm production. For infertile women who wish to bear children, infertility may have a profound emotional toll (Gonzalez, 2000; Hart, 2002).
Pathophysiology Possible causes of infertility include uterine displacement by tumors, congenital anomalies, and inflammation. For an ovum to become fertilized, the vagina, fallopian tubes, cervix, and uterus must be patent and the mucosal secretions of the cervix must be receptive to sperm. Semen and cervical secretions are alkaline, whereas normal vaginal secretions are acidic. Often more than one factor is responsible for the problem. Identifying the causes may require the services of a gynecologist, urologist, and endocrinologist.
Assessment and Diagnostic Findings Careful evaluation includes physical examination, endocrinologic investigation, and consideration of psychosocial factors. Three complete histories (one of each partner and one of the couple), physical examination, and laboratory studies are performed on both partners to rule out such causative factors as previous STDs, anomalies, injuries, tuberculosis, mumps orchitis, impaired sperm production, endometriosis, DES exposure, or antisperm antibodies. Five factors are considered basic to infertility: ovarian, tubal, cervical, uterine, and semen conditions. OVARIAN FACTORS Studies performed to determine if there is regular ovulation and if progestational endometrium is adequate for implantation may include a basal body temperature chart for at least four cycles, an endometrial biopsy, serum progesterone level, and ovulation index. The ovulation index involves a urine-stick test that determines if the surge in LH that precedes follicular rupture has occurred. TUBAL FACTORS Hysterosalpingography is used to rule out uterine or tubal abnormalities. Laparoscopy permits direct visualization of the tubes and other pelvic structures and can assist in identifying conditions that may interfere with fertility (eg, endometriosis). CERVICAL FACTORS The cervical mucus can be examined at ovulation and after intercourse to determine whether proper changes occur that promote sperm penetration and survival. A postcoital cervical mucus
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test (Sims-Huhner test) is performed 2 to 8 hours after intercourse. Cervical mucus is aspirated with a medicine dropper–like instrument. Aspirated material is placed on a slide and examined under the microscope for the presence and viability of sperm cells. The woman is instructed not to bathe or douche between coitus and the examination. UTERINE FACTORS Fibroids, polyps, and congenital malformations are possible conditions in this category. Their presence may be determined by pelvic examination, hysteroscopy, saline sonogram (a variation of a sonogram), and hysterosalpingography. SEMEN FACTORS After 2 to 3 days of sexual abstinence, a specimen of ejaculate is collected in a clean container, kept warm, and examined within 1 hour for the number of sperm (density), percentage of moving forms, quality of forward movement (forward progression), and morphology (shape and form). From 2 to 6 mL of watery alkaline semen is normal; a normal count is 60 million to 100 million sperm/mL, although the incidence of impregnation is lessened only when the count drops below 20 million sperm/mL. A normal semen analysis should show the following (Angard, 1999):
• • • • •
Volume: more than 1 mL Concentration: more than 20 million/mL Motility: more than 50% of the forms should be moving Morphology: more than 60% of sperm should have normal forms No sperm clumping, significant red or white blood cells, or thickening of seminal fluid (hyperviscosity)
MISCELLANEOUS FACTORS Men may also be affected by varicoceles, varicose veins around the testicle, which decrease semen quality by increasing testicular temperature. Retrograde ejaculation or ejaculation into the bladder is assessed by urinalysis after ejaculation. Blood tests for male partners may include measuring testosterone; FSH and LH (both of which are involved in maintaining testicular function); and prolactin levels and antisperm antibodies (treated with corticosteroids). Immunologic factors also are being investigated. Some cases of recurrent early pregnancy loss or recurrent natural abortion are the result of an abnormal response by the woman to antigens on fetal or placental tissues. Some women have been treated with infusions of their partner’s lymphocytes with some success, but this treatment remains experimental and the long-term effects are unknown.
Medical Management Infertility is often difficult to treat because it frequently results from a combination of factors. Couples undergoing an infertility evaluation may conceive without the cause of infertility ever identified. Likewise, although some couples undergo all tests, the cause of the problem may remain undiscovered and infertility persists. Between these extremes, many problems, both simple and complex, can be discovered and corrected. Patients may need assisted reproductive technology to conceive; the methods are described below. Therapy may require surgery to correct a malfunction or anomaly, hormonal supplements, attention to proper timing, and recognition and correction of psychological or emotional factors.
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PHARMACOLOGIC THERAPY Pharmacologically induced ovulation is undertaken when women do not ovulate on their own or ovulate irregularly. Various medications are used, depending on the primary cause of infertility (Chart 46-17). Clomiphene citrate (Clomid) is the most common medication used. Although Clomid’s precise action is unknown, it enhances the release of pituitary gonadotropins, resulting in follicular rupture or ovulation. Another mode of pharmacotherapy for anovulatory women includes the use of pulsatile gonadotropin-releasing hormone (GnRH). The woman wears an infusion pump attached to an intravenous or subcutaneous catheter for up to 21 days. Administration of GnRH can result in ovulation in some women with low hormone levels. This option can reduce cycle monitoring and the incidence of multiple gestation (ACOG Technical Bulletin #197, ACOG Compendium, 2001). Human menopausal gonadotropin may also be used as it stimulates the ovaries to produce eggs. Blood tests and ultrasounds are used to monitor ovulation. Multiple pregnancies may occur with these medications. Ovarian hyperstimulation syndrome (OHSS) may also occur. This condition is characterized by enlarged multicystic ovaries and is complicated by a shift of fluid from the intravascular space into the abdominal cavity. It is iatrogenic and preventable and develops after ovarian stimulation. The fluid shift can result in ascites, pleural effusion, and edema; hypovolemia may also result. Risk factors include younger age, history of polycystic ovarian syndrome, high serum estradiol levels, a larger number of follicles, and pregnancy. If the woman is pregnant, she is producing human chorionic gonadotropin, which can worsen OHSS. Symptoms include abdominal discomfort, distention, weight gain, and ovarian enlargement. This condition may be moderate, severe, or critical. Severe OHSS may result in acute respiratory distress syndrome (ARDS). It is prevented by careful monitoring and adjustment of medication dosage. Management in mild and moderate cases of OHSS consists of decreased activity, monitoring of urine output, and frequent
Chart 46-17
• PHARMACOLOGY
Medications That Induce Ovulation Clomiphene (Clomid) Clomiphene is used when the hypothalamus is not stimulating the pituitary gland to release FSH and LH. This medication stimulates follicles in the ovary. It is usually taken for 5 days beginning on the fifth day of the menstrual cycle. Ovulation should occur 4 to 8 days after the last dose. Patients receive instructions about timing intercourse to facilitate fertilization. Menotropin (Pergonal) Menotropin, a combination of FSH and LH, is used for women with deficiencies in these hormones. Pergonal stimulates the ovaries, so monitoring by ultrasound and hormone levels is essential because overstimulation may occur. Urofollitropin (Metrodin) Urofollitropin, containing FSH with a small amount of LH, is used in some disorders (eg, polycystic ovarian syndrome) to stimulate follicle growth. Clomid is then used to stimulate ovulation. Chorionic Gonadotropin Chorionic gonadotropin is used to stimulate release of the egg from the ovary and may be used in combination with the above medications.
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office visits as designated by the reproductive endocrinologist. The patient with severe OHSS is hospitalized for monitoring and treatment. Severe OHSS is characterized by clinical ascites, hypovolemia, oliguria, hemoconcentration, electrolyte imbalance, and ovarian size greater than 10 cm. Treatment of severe OHSS includes use of an indwelling catheter for strict monitoring of fluid intake and output and daily measurements of weight and abdominal circumference. Intravenous fluids and heparin are administered as prescribed. The patient is permitted to ambulate as tolerated. Critical OHSS is life-threatening and is characterized by tense ascites that may be accompanied by hydrothorax, renal failure, and ARDS. Volume expanders, diuretic agents, hemodialysis, and intubation may be required (Copeland, 2000). ARTIFICIAL INSEMINATION Depositing semen into the female genital tract by artificial means is called artificial insemination. If the sperm cannot penetrate the cervical canal normally, artificial insemination using the partner’s semen (AIH, or artificial insemination with sperm from the husband or partner) may be considered. In azoospermia (lack of sperm in the semen), semen from carefully selected donors may be used (AID, or artificial insemination with sperm from donor). Indications for using artificial insemination include: (1) the man’s inability to deposit semen in the vagina, which may be due to premature ejaculation, pronounced hypospadias (a displaced male urethra), or dyspareunia (painful intercourse experienced by the woman), (2) inability of semen to be transported from the vagina to the uterine cavity (this is usually due to faulty chemical conditions and may occur with an abnormal cervical discharge), and (3) a single woman’s desire to have a child. The woman may have received clomiphene (Clomid) and menotropins (Pergonal) to stimulate ovulation before insemination. Ultrasounds and blood studies of varying hormone levels are used to pinpoint the best time for insemination and to monitor for OHSS. The recipient is placed in the lithotomy position on the examination table, a speculum is inserted, and the vagina and cervix are swabbed with a cotton-tipped applicator to remove any excess secretions. Semen is drawn into a sterile syringe, and a cannula is attached. The semen is then directed to the external os. Semen may also be placed into the uterine cavity (intrauterine insemination). In this procedure, the sperm are washed before insertion to remove biochemicals and to select the most active sperm. This is indicated when mucus is inadequate, when antibodies are present, or when the sperm count is low. After careful withdrawal of the cannula, the patient remains in a supine position for 30 minutes. The success rate for artificial insemination varies. Three to six inseminations may be required over 2 to 4 months. Because artificial insemination is likely to be a stressful and difficult situation for couples, nursing support and strategies to promote coping are crucial. Cannula With Partner’s Semen. Certain conditions need to be established before semen is transferred to the vagina. The woman must have no abnormalities of the genital system, the fallopian tubes must be patent, and ova must be available. In the male, sperm need to be normal in shape, amount, motility, and endurance. The time of ovulation should be determined as accurately as possible so that the 2 or 3 days during which fertilization is possible each month can be targeted for treatment. Fertilization
seldom occurs from a single insemination. Usually, insemination is attempted between days 10 and 17 of the cycle; three different attempts may be made during one cycle. Semen is collected by masturbation; alternatively, a perforated sheath is worn over the penis during intercourse by couples who object to masturbation. Withdrawal and using condoms for sperm collection are considered unsatisfactory by many infertility specialists because some sperm may be lost or adversely affected. Insemination With Donor Semen. When the sperm of the woman’s partner is defective or absent or when there is a risk of transmitting a genetic disease, donor sperm may be used. Safeguards are put in place to address legal, ethical, emotional, and religious issues. Written consent is obtained to protect all parties involved, including the woman, the donor, and the resulting child. The donor’s semen is frozen and the donor is evaluated to ensure that he is free of genetic disorders and STDs, including HIV infection. IN VITRO FERTILIZATION In vitro fertilization (IVF) involves ovarian stimulation, egg retrieval, fertilization, and embryo transfer. This procedure is accomplished by first stimulating the ovary to produce multiple eggs or ova, usually with medications, because success rates are greater with more than one early embryo. Many different protocols exist for inducing ovulation with one or more agents. Patients are carefully selected and evaluated, and cycles are carefully monitored using ultrasound and estradiol levels. At the appropriate time, the ova are recovered by transvaginal ultrasound retrieval. Sperm and eggs are coincubated for up to 36 hours, and the embryos are transferred about 48 hours after retrieval. Implantation should occur in 3 to 5 days. Gamete intrafallopian transfer (GIFT), a variation of IVF, is the treatment of choice for patients with ovarian failure. Success rates vary from 20% to 30%. The ovaries are stimulated with gonadotropin derivatives, and follicles are observed with vaginal ultrasound. Once the oocyte is mature, it is retrieved by laparoscopy or transvaginally with ultrasound guidance. The oocyte (unfertilized egg) is removed and drawn into a catheter, where it is mixed with sperm that was obtained shortly before the oocyte retrieval. The most motile fraction of sperm is selected by a washing process. The oocyte and sperm are then inserted into the fallopian tube, where fertilization occurs. The latter method avoids anesthesia. GIFT is the technique of choice for nontubal causes of infertility and for older infertile women. Zygote intrafallopian transfer (ZIFT) consists of oocyte retrieval and fertilization in vitro; the zygotes are placed into the fallopian tubes via laparoscopy. The most common indications for IVF and GIFT are irreparable tubal damage, endometriosis, immunologic problems, unexplained infertility, inadequate sperm, and exposure to DES. OTHER ASSISTED REPRODUCTIVE TECHNOLOGIES In intracytoplasmic sperm injection (ICSI), an ovum is retrieved as described previously, and a single sperm is injected through the zona pellucida, through the egg membrane, and into the cytoplasm of the oocyte. The fertilized egg is then transferred back to the donor. ICSI is the treatment of choice in severe male factor infertility. Women who cannot produce their own eggs (ie, premature ovarian failure) have the option of using the eggs of a donor after
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stimulation of the donor’s ovaries. The recipient also receives hormones in preparation for these procedures. Couples may also choose this modality if the female partner has a genetic disorder that may be passed on to children.
Nursing Management Nursing interventions appropriate when working with couples during infertility evaluations include the following: assist in reducing stress in the relationship, encourage cooperation, protect privacy, foster understanding, and refer the couple to appropriate resources when necessary. Because infertility workups are expensive, time-consuming, invasive, stressful, and not always successful, couples need support in working together to deal with this endeavor. Resolve, Inc., a nonprofit self-help group that provides information and support for infertile patients, was founded by a nurse who experienced difficulty conceiving. The literature on infertility that is produced by this group is an important resource for patients and professionals. Most areas across the country have local support groups. More information can be obtained by writing to Resolve, Inc. (see the address at the end of this chapter). Smoking is strongly discouraged because it has an adverse effect on the success of assisted reproduction. Diet, exercise, stress reduction techniques, health maintenance, and disease prevention are being emphasized in many infertility programs.
ECTOPIC PREGNANCY The incidence of ectopic pregnancy is on the rise: it occurs in 2% of pregnancies (Lemus, 2000). It occurs when a fertilized ovum (a blastocyst) becomes implanted on any tissue other than the uterine lining (eg, the fallopian tube, ovary, abdomen, or cervix; Fig. 46-9). The most common site of ectopic implantation is the fallopian tube. Possible causes include salpingitis, peritubal adhesions (after pelvic infection, endometriosis, appendicitis), structural abnormalities of the fallopian tube (rare and usually related to DES exposure), previous ectopic pregnancy (after one ectopic pregnancy, the risk of recurrence is 7% to 15%; Lemus, 2000), previous tubal surgery, multiple previous induced abortions (particularly if followed by infection), tumors that distort the tube, and IUD and progestin-only contraceptives. PID appears to be the major risk factor for ectopic pregnancy. Improved antibiotic therapy for PID usually prevents total tubal closure but may leave a stricture or narrowing, predisposing the woman to ectopic implantation. The odds of recurrent ectopic pregnancy are three times higher if an infectious pathology was the cause of the first one. If a woman has a second ectopic pregnancy, assisted reproduction is considered. The rate of tubal pregnancies has increased in disproportion to population growth. Ectopic pregnancies are being diagnosed sooner and more often because of advanced diagnostic techniques. Moreover, they are being treated conservatively before emergency rupture and hemorrhage occur. It may be that the increased numbers result from better diagnostic techniques. Conservative treatment makes ectopic pregnancy less life-threatening than previously, but this condition persists as the leading cause of pregnancy-related death in the first trimester and the second leading cause of maternal mortality in the United States. Ectopic pregnancy is also a complication of IVF.
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NURSING RESEARCH PROFILE 46-1
The Experience of Premature Ovarian Failure Orshan, S. A., Furniss, K. K., Forst, C., & Santoro, N. (2001). The lived experience of premature ovarian failure. JOGNN, 30(2), 202–207.
Purpose Premature ovarian failure (POF), the premature cessation of function of the ovaries, affects 1% to 5% of women below the age of 40. Little is known about the impact of POF on women who experience it and their reactions to the diagnosis. The purpose of this study was to describe the experiences of women diagnosed with idiopathic POF. Study Sample and Design A qualitative research study using phenomenology was used. Six women who experienced idiopathic POF before the age of 35 were asked to describe the meaning of POF to them. The subjects ranged in age from 25 to 41 at the time of the interview; mean age was 36.7 years. Five of the women were Caucasian; one was African American. Four of the six women had ceased menstruating between 5 and 10 years before the interview. Interviews were conducted in private settings; the women were asked to share what it had been like to live with POF and to describe the reactions of their family and friends to the diagnosis of POF. Audiotapes of the interviews were transcribed and analyzed. Findings Four major themes emerged from analysis of the interview data: 1) being treated as a diagnosis rather than as a person, 2) grieving for death of a dream for the future, 3) existing in a world with others, most of whom are fertile, and 4) being too young to be so old. The women in the study reported feeling robbed of their ability to have children and robbed of their youth with the premature onset of menopause. Women reported reacting to the diagnosis of POF with feelings of anger, depression, grief, and mourning. Nursing Implications Nurses need to be sensitive to the impact that POF has on women and need to create a supportive environment for women who experience premature menopause. While POF is not a common diagnosis, women who experience it might benefit from health care providers who listen to their concerns, provide support, teach, and make appropriate referrals. Recognizing the impact the diagnosis has on women is important for nurses caring for women with POF.
Clinical Manifestations Early intervention decreases rupture, minimizes tubal damage, and usually avoids the need for surgery. Signs and symptoms vary depending on whether tubal rupture has occurred. Delay in menstruation from 1 to 2 weeks followed by slight bleeding (spotting) or a report of a slightly abnormal period suggests the possibility of an ectopic pregnancy. Symptoms may begin late, with vague soreness on the affected side, probably due to uterine contractions and distention of the tube. Typically, the patient experiences sharp, colicky pain. Most patients experience pelvic or abdominal pain and some spotting or bleeding. Gastrointestinal symptoms, dizziness, or lightheadedness is common. The patient frequently thinks the abnormal bleeding is a menstrual period, especially if a recent period occurred and was normal. If implantation occurs in the fallopian tube, the tube becomes more and more distended and can rupture if the ectopic pregnancy
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Unit 10
REPRODUCTIVE FUNCTION Tubal (isthmus) Abdominal
Interstitial
Tubal (ampullar) Infundibular (ostial)
Ovarian
Cervical
FIGURE 46-9
Sites of ectopic pregnancy.
remains undetected for 4 to 6 weeks or longer after conception. When the tube ruptures, the ovum is discharged into the abdominal cavity. When tubal rupture occurs, the woman experiences agonizing pain, dizziness, faintness, and nausea and vomiting. These symptoms are related to the peritoneal reaction to blood escaping from the tube. Air hunger and symptoms of shock may occur, and the signs of hemorrhage—rapid and thready pulse, decreased blood pressure, subnormal temperature, restlessness, pallor, and sweating—are evident. Later, the pain becomes generalized in the abdomen and radiates to the shoulder and neck because of accumulating intraperitoneal blood that irritates the diaphragm.
Assessment and Diagnostic Findings During vaginal examination, a large mass of clotted blood that has collected in the pelvis behind the uterus or a tender adnexal mass may be palpable. If an ectopic pregnancy is suspected, the patient is evaluated by sonography and the beta subunit of human chorionic gonadotropin (hCG) levels. If the ultrasound results are inconclusive, the beta-hCG test is repeated to evaluate the rate of rise in the level. The levels of hCG (the diagnostic hormone of pregnancy) double in early normal pregnancies every 3 days but are reduced in abnormal or ectopic pregnancies. A less-than-normal increase is cause for suspicion. Serum progesterone levels are also measured. Levels under 5 ng/mL are considered abnormal; levels over 25 ng/mL are associated with a normally developing pregnancy. Urine tests for pregnancy are not helpful in ectopic pregnancies. Ultrasound can detect a pregnancy between 5 and 6 weeks from the last menstrual period. Detectable fetal heart movement outside the uterus on ultrasound is firm evidence of an ectopic pregnancy. On occasion, an ultrasound study is not definitive and the diagnosis must be made with combined diagnostic aids (hCG level, ultrasound, pelvic examination, and clinical judgment). Studies using ultrasound with Doppler flow, in which color indicates perfusion, are helpful. Occasionally, the clinical picture makes the diagnosis relatively easy. However, when the clinical signs and symptoms are
questionable, which is often the case, other procedures have value. Laparoscopy is used because the physician can visually detect an unruptured tubal pregnancy and thereby circumvent the risk of its rupture.
Medical Management SURGICAL MANAGEMENT When surgery is performed early, almost all patients recover rapidly; if tubal rupture occurs, mortality increases. The type of surgery is determined by the size and extent of local tubal damage. Conservative surgery would include “milking” an ectopic pregnancy from the tube. Resection of the involved fallopian tube with end-to-end anastomosis may be effective. Some surgeons attempt to salvage the tube with a salpingostomy, which involves opening and evacuating the tube and controlling bleeding. More extensive surgery includes removing the tube alone (salpingectomy) or with the ovary (salpingo-oophorectomy). Depending on the amount of blood lost, blood component therapy and treatment of hemorrhagic shock may be necessary before and during surgery. Surgery may also be indicated in women unlikely to comply with close monitoring or those who live too far away from a health care facility to obtain the monitoring needed with nonsurgical management. Methotrexate, a chemotherapeutic agent and folic acid antagonist, is used after surgery to treat any remaining embryonic or early pregnancy tissue, as indicated by a persistent or rising betahCG level. The beta-hCG test is repeated 2 weeks after surgery to ensure a falling level. PHARMACOLOGIC THERAPY Another option is the use of methotrexate without surgery. Because this medication stops the pregnancy from progressing by interfering with DNA synthesis and the multiplication of cells, it interrupts early, small, unruptured tubal pregnancies. Patients must be hemodynamically stable, have no active renal or hepatic disease, have no evidence of thrombocytopenia or leukopenia, and have a very small, unruptured tubal pregnancy on ultrasound. The medication
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is administered intramuscularly or intravenously. Some patients may be treated with intratubal injection of methotrexate. Complete blood count, blood typing, and tests of liver and renal function are conducted to monitor the patient. The patient is advised to refrain from alcohol, intercourse, and vitamins with folic acid until the pregnancy is resolved because these may exacerbate the adverse effects of methotrexate. Abdominal pain may occur within 5 to 10 days and may indicate termination of the pregnancy. This requires careful assessment by the health care provider. Serum levels of hCG are monitored carefully, and these levels should gradually decrease. Ultrasounds may also be used for monitoring. Side effects of methotrexate include stomatitis and diarrhea, bone marrow suppression, impaired liver function, dermatitis, and pleuritis.
NURSING PROCESS: THE PATIENT WITH AN ECTOPIC PREGNANCY Assessment The health history includes the menstrual pattern and any (even slight) bleeding since the last menstrual period. The nurse elicits the patient’s description of pains and their location. The nurse asks the patient whether any sharp, colicky pains have occurred. Then the nurse notes whether pain radiates to the shoulder and neck (possibly caused by rupture and pressure on the diaphragm). The nurse monitors vital signs, level of consciousness, and nature and amount of vaginal bleeding. If possible, the nurse assesses how the woman is coping with the loss of a pregnancy.
Diagnosis NURSING DIAGNOSES Based on the assessment data, the patient’s major nursing diagnoses may include the following:
• Acute pain related to the progression of the tubal pregnancy • Anticipatory grieving related to the loss of pregnancy and effect on future pregnancies
• Deficient knowledge related to the treatment and effect on future pregnancies
COLLABORATIVE PROBLEMS/ POTENTIAL COMPLICATIONS Based on the assessment data, major complications may include the following:
• Hemorrhage • Hemorrhagic shock Planning and Goals The major goals for the patient may include relief of pain; acceptance and resolution of grief and pregnancy loss; increased knowledge about ectopic pregnancy, its treatment, and its outcome; and absence of complications.
Nursing Interventions RELIEVING PAIN The abdominal pain associated with ectopic pregnancy may be described as cramping or severe continuous pain. If the patient is to have surgery, preanesthetic medications may provide pain relief. Postoperatively, analgesic agents are administered liberally;
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this promotes early ambulation and enables the patient to cough and take deep breaths. SUPPORTING THE GRIEVING PROCESS Patients’ distress levels vary. If the pregnancy is wanted, loss may or may not be expressed verbally by the patient and her partner. The impact may not be fully realized until much later. The nurse should be available to listen and provide support. The patient’s partner, if appropriate, should participate in this process. Even if the pregnancy was unplanned, a loss has been experienced, and a grief reaction may follow. Severe and persistent psychological distress may require referral for psychological counseling. MONITORING AND MANAGING POTENTIAL COMPLICATIONS Potential complications of ectopic pregnancy are hemorrhage and shock. Careful assessment is essential to detect the development of these complications. Continuous monitoring of vital signs, level of consciousness, amount of bleeding, and intake and output provides information about the possibility of hemorrhage and the need to prepare for intravenous therapy. Bed rest is indicated. Hematocrit, hemoglobin, and blood gas levels are monitored to assess hematologic status and adequacy of tissue perfusion. Significant deviations in these laboratory values are reported immediately, and the patient is prepared for possible surgery. Blood component therapy may be required if blood loss has been rapid and extensive. If hypovolemic shock occurs, the treatment is directed toward re-establishing tissue perfusion and adequate blood volume. See Chapter 15 for a discussion of the intravenous fluids and medications used in treating shock. PROMOTING HOME AND COMMUNITY-BASED CARE Teaching Patients Self-Care If the patient has experienced life-threatening hemorrhage and shock, these complications are addressed and treated before any indepth teaching can begin. At this time, the patient’s and the nurse’s attention is focused on the crisis, not on learning. Therefore, it may be later that the patient begins to ask questions about what has happened and why certain procedures were performed. Procedures are explained in terms that a distressed and apprehensive patient can understand. The patient’s partner is included in teaching and explanations when possible. After the patient recovers from postoperative discomforts, it may be more appropriate to address any questions and concerns that the patient and her partner have, including the effect of this pregnancy or its treatment on future pregnancies. Patients should be advised that ectopic pregnancies may recur. It is important to review signs and symptoms with the patient and instruct her to report an abnormal menstrual period promptly. Patient teaching is based on the needs of the patient and her partner and must take into consideration their distress and grief. The patient is informed about possible complications and instructed to report early signs and symptoms. Continuing Care Because of the risk of subsequent ectopic pregnancies, the patient is advised to seek preconception counseling before considering future pregnancies and to seek early prenatal care. Psychological support and counseling may be advisable for women and their partners to help them deal with the loss of the pregnancy. Follow-up contact enables the nurse to answer questions and clarify information for the woman and her partner. In addition, it provides an opportunity to assess their ability to cope with the loss of the pregnancy.
Unit 10
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Evaluation EXPECTED PATIENT OUTCOMES Expected patient outcomes may include: 1. Experiences relief of pain a. Reports a decrease in pain and discomfort b. Ambulates as prescribed; performs coughing and deep breathing 2. Begins to accept loss of pregnancy and expresses grief by verbalizing feelings and reactions to loss 3. Verbalizes an understanding of the causes of ectopic pregnancy 4. Experiences no complications a. Exhibits no signs of bleeding, hemorrhage, or shock b. Has decreased amounts of discharge (on perineal pad) c. Has normal skin color and turgor d. Exhibits stable vital signs and adequate urine output e. Levels of beta-hCG return to normal
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Critical Thinking Exercises
1.
A 25-year-old woman is having a complete physical examination for the first time and is extremely apprehensive. How would you approach the history and physical examination with her? How would you modify your approach if the woman had significant physical and developmental/ cognitive disabilities?
2.
A 57-year-old woman with osteoporosis has been taking hormone replacement therapy (HRT) for 9 years to treat hot flashes and to prevent further bone loss. She has recently read about the results of the Women’s Health Initiative study suggesting that the risks of HRT outweigh the benefits. She is concerned not only about her risk for breast cancer based on those results, but also about the return of hot flashes and further bone loss if she stops the HRT. How would you advise her? What resources would you recommend to her?
3.
An 18-year-old woman comes to the clinic for a gynecologic examination because she anticipates having sex with her new boyfriend. She asks you for advice about oral contraceptives versus barrier methods of contraception. What advice would you give her? How would you teach her about using a barrier method of contraception if that is what she chooses? How would you modify your teaching if she informed you that her new boyfriend has AIDS? What general health promotion teaching would you provide to her?
4.
You are working in an infertility practice and are responsible for orienting couples beginning an evaluation for infertility to the procedures and services of the practice. A 40-year-old woman and her 48-year-old husband are eager to learn about the process. During your initial conversation with them, you learn that they both have high levels of stress and high-pressure jobs. While the woman is eager to begin the process, her husband is uncertain about wanting to proceed with the workup because of concerns about privacy, confidentiality, costs, and possible disappointment. How would you proceed in your explanations of the process
and procedures? What information about your assessment of the couple’s readiness to undergo the evaluation would you report to the physician or nurse practitioner?
5.
During a checkup at the clinic where you work, a 43-year-old patient tells you that she has met a new partner and is not concerned about sexual risks of STDs because she is a lesbian and has never had a sexual relationship with a man. How would you address the educational needs of this patient?
6.
At a health clinic, you meet a 48-year-old woman with spina bifida who uses a cane at home and a wheelchair outside the home. She is approaching menopause and is concerned about how her limitations secondary to spinal bifida might affect her health related to menopause. Describe what health promotion issues would be relevant and the actions, including patient teaching, that are warranted.
REFERENCES AND SELECTED READINGS Books American College of Obstetricians and Gynecologists (ACOG). 2001 Compendium of selected publications. Washington, DC: Author. Andrews, M., & Boyle, J. (Eds.) (2001). Transcultural concepts in nursing care (3d ed.). Philadelphia: Lippincott William & Wilkins. Annon, J. S. (1976). Behavioral treatment of sexual problems: Brief therapy. Hagerstown, MD: Harper & Row. AWHONN (1999). Women’s health at midlife and beyond: Nursing practice for wellness promotion and disease prevention. Monograph 1: Postmenopausal health risks and the importance of prevention. A CE Self-Study Series for Nurses. Washington, DC: Author. Copeland, L. (2000). Textbook of gynecology (2d ed.). Philadelphia: W. B. Saunders. Goldman, M., & Hatch, M. (2000). Women and health. San Diego: Academic Press. Hawkins, J., Roberto-Nichols, D., & Stanley-Haney, J. (1999). Protocols for nurse practitioners in gynecologic setttings (7th ed.). New York: Tiresias Press. Kirschner, K. L., Gill, C. J., Reis, J. P., & Welner, S. (1998). Health issues for women with disabilities. In J. A. DeLisa & B. M. Gans, Rehabilitation medicine: Principles and practice (3d ed.). Philadelphia: Lippincott-Raven. National Osteoporosis Foundation. (1999). Physician’s guide to prevention and treatment of osteoporosis. Washington, DC: Author. North American Menopause Society (2000). Menopause core curriculum study guide. Cleveland: Author (http://www.menopause.org). Northrup, C. (1998). Women’s bodies, women’s wisdom: Creating physical and emotional health and healing. New York: Bantam. U.S. Department of Health and Human Services. (2001). Surgeon general’s call to action to promote sexual health and responsible sexual behavior. Washington, DC: U.S. Government Printing Office. Toubia, N. (1999). Caring for women with circumcision. New York: Rainbow. Varicchio, C. (1997). A cancer source book for nurses (7th ed.). Atlanta: American Cancer Society.
Journals Asterisks indicate nursing research articles. General ACOG (2001). Antibiotic prophylaxis for gynecologic procedures. ACOG Practice Bulletin #23. Obstetrics & Gynecology, 97(4), 1–13. Asch-Goodkin, J. (2001). Caring for the postmenopausal woman: Complete care of the older woman. Patient Care for the Nurse Practitioner, 4(5), 15–22.
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Asch-Goodkin, J. (2001). Complete care of the older woman. Patient Care, 35(9), 23–34. Centers for Disease Control and Prevention (CDC). (2002). Sexually transmitted diseases treatment guidelines, 2002. MMWR-Morbidity and Mortality Weekly Report, 51(RR-6), 1–85. Charney, P. (2000). Women’s health: An evolving mosaic. Journal of General Internal Medicine, 15(8), 600–602. Kopac, C., Fritz, J., & Holt, R. (1998). Gynecologic and reproductive services for women with developmental disabilities. Clinical Excellence for Nursing Practice, 2(2), 88–95. *Lamp, J. Alteneder, R., & Lee, C. (2000). Nurses’ knowledge, attitude and skills related to sexuality. Journal of Nursing Scholarship, 32(4), 391. McFarlane, M., Bull, S., & Rietmeijer, C. (2000) The Internet as a newly emerging risk environment for sexually transmitted diseases. Journal of the American Medical Association, 284(4), 443–446. Muscari, M. E. (1999). Adolescent health: The first gynecologic exam. American Journal of Nursing, 99(1), 66–67. Peck, S. A. (2001). The importance of the sexual health history in the primary care setting. Journal of Obstetric, Gynecologic and Neonatal Nursing, 30(3), 269–274. Sandelowski, M. (2000). “This most dangerous instrument”: Propriety, power and the vaginal speculum. JOGNN, 29(1), 73–82. Smeltzer, S. C. (2000). Double jeopardy: Women with disabilities. American Journal of Nursing, 100(8), 11. Abortion Abortion surveillance: preliminary analysis—United States, 1997. (2000). MMWR, Morbidity & Mortality Weekly Reports, 48(51/52), 1171–1174, 1191. ACOG Committee on Practice Bulletins—Gynecology. (2001). Medical management of abortion. Clinical management guidelines for obstetrician-gynecologists. ACOG Practice Bulletin #26. Obstetrics & Gynecology, 97(4), suppl 1–13. ACOG (2000). Mifepristone for medical pregnancy termination. ACOG Committee on Gynecologic Practice Committee Opinion #245. Obstetrics & Gynecology, 96(6), 1–2. Borgatta, L., Burnhill, M., Tyson, J., et al. (2001). Early medical abortion with methotrexate and misoprostol. Obstetrics & Gynecology, 97(1), 11–16. Christin-Maitre, S., Bouchard, P., & Spitz, I., (2000). Medical termination of pregnancy. New England Journal of Medicine, 342(13), 946–955. Goldberg, A., Greenberg, M., & Darney, P. (2001). Drug therapy: Misoprostol and pregnancy. New England Journal of Medicine, 344(1), 38–47. Hale, R., & Zinberg, S. (2001). Use of misoprostol in pregnancy. New England Journal of Medicine, 344(1), 59–60. Robinson, D., Dollins, A., & O’Shaughnessy, L. (2000). Care of the woman before and after an elective abortion. American Journal for Nursing Practice, 4(3), 17–29. Williams, G. (2000). Grief after elective abortion. AWHONN Lifelines, 4(2), 37–40. Zapka, J., Lemon, S., Peerson, et al. (2001). The silent consumer: Women’s reports and ratings of abortion services. Medical Care, 39(1), 50–60. Conception Control ACOG (2001). Managing the anovulatory state: medical induction of ovulation. ACOG Technical Bulletin #197. ACOG 2001 Compendium of Selected Publications, 596–601. ACOG (1995). Hormonal contraception. ACOG Technical Bulletin #198. International Journal of Gynecology & Obstetrics, 48(1), 115–126. ACOG Committee on Ethics. (1999). Sterilization of women, including those with mental disabilities. ACOG Committee Opinion # 216. International Journal of Gynecology & Obstetrics, 65(3), 317–320. Barron, M., & Daly, K. (2001). Expert in fertility appreciation: The Creighton model practitioner. Journal of Obstetric, Gynecologic and Neonatal Nursing, 30(4), 386–391.
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CDC (1999). Achievements in public health, 1990–1999: Family planning. MMWR, Morbidity & Mortality Weekly Reports, 48, 1073–1080. CDC (2001). Emergency contraception direct from the pharmacist. Contraceptive Technology Update, 22(1), 1–12. Christman, G., & Uechi, H. (May 2000). Female sterilization. Female Patient, 25(5), 29–35. ———(2000). Evolution and revolution; the past, present and future of contraception. Contraception Report, 10(6), 15–25. Farrington, A. (2001). Today’s contraceptive options: Finding the right fit. Health and Sexuality, 6(3), 4–6. Grabrick, D., Hartman, L., Cerhan, J., et al. (2000). Risk of breast cancer with oral contraceptive use in women with a family history of breast cancer. Journal of the American Medical Association, 284(14), 1791–1798. Grimes, D., & Raymond, E. (1999). Bundling a pregnancy test with the Yupze regimen of emergency contraception. Obstetrics & Gynecology, 94(3), 471–473. Grydanus, D., Patel, D., & Rimsza, M. (2001). Contraception in the adolescent: An update. Pediatrics, 107(3), 562–573. Jamieson, D., Hillis, S., Duerr, A., et al. (2000). Complications of interval laparoscopic tubal sterilization: Findings from the United States Collaborative Review of Sterilization. Obstetrics & Gynecology, 96(6), 997–1002. Morris, B. J., & Young, C. (2000). Emergency contraception. American Journal of Nursing, 100(9), 46–48. Peterson, H. B., Xia, Z., Wilcox, L. S., et al. (2001). Collaborative Review of Sterilization Working Group. Pregnancy after tubal sterilization with silicone rubber band and spring clip application. Obstetrics & Gynecology, 97(2), 205–210. Rawlins, S., Burkman, R., & Schwarz, B. (2000). The power of the pill: Making evidence-based decisions. American Journal of Nursing Practice, 4(1), 25–40. Schnare, S. (2000). Emergency postcoital contraception. American Journal of Nursing Practice, 4(2), 15–22. Stephenson, J. (2000). Widely used spermicide may increase, not decrease risk of HIV transmission. Journal of the American Medical Association, 284(8), 949. Cultural Differences in Health Care of Women ACOG Committee on Health Care for Underserved Women (1998). Cultural competency in health care. ACOG Committee Opinion #201. International Journal of Gynecology & Obstetrics, 62(1), 96–99. Blackwell, D., & Blackwell, J. (1999). Building alternative families: Helping lesbian couples find the path to parenthood. AWHONN Lifelines, 3(5), 45–48. Carroll, N. (1999). Optimal gynecologic and obstetric care for lesbians. Obstetrics & Gynecology, 93(4), 611–613. Cesario, S. (2001) Care of the native American woman: Strategies for practice education and research. Journal of Obstetric, Gynecologic and Neonatal Nursing, 30(1), 13–18. Cochran, S. D., Mays, V. M., Bowen, D., et al. (2001). Cancer-risk risk indicators and preventive screening behaviors among lesbians and bisexual women. American Journal of Public Health, 91(4), 591–597. Mattson, S. (2000) Providing culturally competent care: Strategies and approaches for perinatal clients. AWHONN Lifelines, 4(5), 37–39. Sinclair, B. (2000). Putting cultural competence into practice. AWHONN Lifelines, 4(2), 7–8. Diagnostic Techniques and Treatments ACOG (1997). Operative laparoscopy. ACOG Educational Bulletin #239. International Journal of Gynecology & Obstetrics, 59(3), 265–268. ACOG Committee on Gynecologic Practice. (1998). Role of loop electrosurgical excision procedure in the evaluation of abnormal Pap test results. ACOG Committee Opinion #195. International Journal of Gynecology & Obstetrics, 61(2), 203–204. Farquhar, C., Lethaby, A., Sowter, M., et al. (1999). An evaluation of risk factors for endometrial hyperplasia in premenopausal women with abnormal menstrual bleeding. American Journal of Obstetrics & Gynecology, 181(3), 525–529.
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Klein, A., & Schwartz, M. (2001). Uterine artery embolization of uterine fibroids: An outpatient procedure. American Journal of Obstetrics & Gynecology, 184(7), 1556–1563. Soriano, D., Ajaj, S. Chuong, T., et al. (2000). Lidocaine spray and outpatient hysteroscopy: Randomized placebo controlled trial. Obstetrics & Gynecology, 96(5, Part 1), 661–664. Suh-Burghman, E., Whall-Strojwas, D., Chang, Y., et al. (2000). Risk factors for cervical stenosis after loop electrocautery excision procedure. Obstetrics & Gynecology, 96(5, Part 1), 657–660. Tjarks, M., & Van Voorhis, B. (2000). Treatment of endometrial polyps. Obstetrics & Gynecology, 96(6), 886–889. Ectopic Pregnancy Buster, J., & Heard, M. (2000). Current issues in medical management of ectopic pregnancy. Current Opinion in Obstetrics & Gynecology, 12(6), 525–527. Garcia, C., & Barnhart, K. (2001). Diagnosing ectopic pregnancy: Decision analysis comparing six strategies. Obstetrics & Gynecology, 97(3), 464–470. Lemus, J. (2000). Ectopic pregnancy: An update. Current Opinion in Obstetrics & Gynecology, 12(5), 369–375. Lipscomb, G., Stovall, T., & Ling, F. (2000). Primary care: Nonsurgical treatment of ectopic pregnancy. New England Journal of Medicine, 343(18), 1325–1329. Morlock, R., Lafata, J., & Eisenstein, D. (2000). Cost-effectiveness of single-dose methotrexate compared with laparoscopic treatment of ectopic pregnancy. Obstetrics & Gynecology, 95(3), 407–412. Infertility ACOG (2000). Infertility. ACOG Technical Bulletin #125. 2001 Compendium of Selected Publications Compendium, 556–561. Angard, N. (1999). Diagnosis: Infertility. AWHONN Lifelines, 3(3), 22–29. Cramer, D., Liberman, J., Powers, D., et al. (2000). Recent trends in assisted reproductive techniques and associated outcomes. Obstetrics & Gynecology, 95(1), 61–66. DeMaio, C. (Spring 2000). Clomiphene for infertility? When to refer. Conversations in Counseling, 2(1), 4–6. Gonzalez, L. O. (2000). Infertility as a transformational process: A framework for psychotherapeutic support of infertile women. Issues in Mental Health Nursing, 21(6), 619–633. Guermandi, E., Vegetti, W., Massimiliano, M. et al. (2001). Reliability of ovulation tests in infertile women. Obstetrics & Gynecology, 97(1), 92–96. Hart, V. A. (2002). Infertility and the role of psychotheraphy. Issues in Mental Health Nursing, 23(1), 31– 41. Van Voorhis, B., & Syrop, C. (2000). Cost-effective treatment of the couple with infertility. Clinical Obstetrics and Gynecology, 43(4), 958–973. Menstruation, Irregular Bleeding, Perimenopause, PMS, and Menopause Akin, M., Weingand, K., Hengehold, D., et al. (2001). Continuous lowlevel topical heat in the treatment of dysmenorrhea. Obstetrics & Gynecology, 97(3), 343–349. American Association of Clinical Endocrinologists (1999). Medical guidelines for clinical practice for management of menopause. Endourinology Practice, 5(6), 355–366. American Heart Association. Questions and answers about HRT. http://www.americanheart.org (accesssed August 10, 2002). Bachmann, G. (2001). Physiologic aspects of natural and surgical menopause. Journal of Reproductive Medicine, 46(3 Suppl), 307–315. Barnard, N., Scialli, A., Hurlock, D., & Bertron, P. (2000) Diet and sexhormone binding globulin, dysmenorrhea and premenstrual symptoms. Obstetrics & Gynecology, 95(2), 245–250. Dell, D., Moskowitz, D., & Sondheimer, S. (2001). PMS and PMDD: Identification and treatment. Contemporary Obstetrics & Gynecology, 46(4), 15–24. DeMasters, J. (2000). HRT and menopause: A clinician’s guide to understanding the dilemma. AWHONN Lifelines, 4(2), 26–35. DiCarlo, C., Palomba, S., Tommaselli, G., et al. (2001). Use of leuprolide acetate plus tibolone in the treatment of severe premenstrual syndrome. Fertility & Sterility, 75(2), 380–384.
Finkel, M. L., Cohen, M., & Mahoney, H. (2001). Treatment options for the menopausal woman. Nurse Practitioner, 26(2), 5–7, 11–17. Goolsby, M. J. (2001). Clinical practice guidelines. Management of menopause. Journal of the American Academy of Nursing Practice, 13(4), 147–151. Grady, D., Brown, J., Vittinghoff, E., et al. (2001). Postmenopausal hormones and incontinence: The heart and estrogen/progestin replacement study. Obstetrics & Gynecology, 97(1), 116–120. Hulley, S., Grady, D., Bush, T., et al. (1998). Randomized trial of estrogen plus progestin for secondary prevention of coronary heart disease in postmenopausal women. Heart and Estrogen/progestin Replacement Study (HERS) Research Group. Journal of the American Medical Association, 280(7), 605–613. Kessenich, C. (2000). Osteoporosis in primary care: Role of biochemical markers and diagnostic imaging. American Journal of Nursing Practice, 4(2), 24–29. Manson, J., & Martin, K. (2001). Post-menopausal hormone-replacement therapy. New England Journal of Medicine, 345(1), 34–40. Mishell, D. (2000). Oral contraceptives: Making evidence-based decisions. International Journal of Fertility, 45(Suppl 2), 99–150. Morse, G. (1999). Positively reframing perceptions of the menstrual cycle among women with premenstrual syndrome. Journal of Obstetric, Gynecologic and Neonatal Nursing, 28(2), 165–174. Mosca, L., Collins, P., Herrington, D., et al. (2001). Hormone replacement therapy and cardiovascular disease: A statement for health care professionals from the American Heart Association. Circulation, 104(4), 499–503. National Institutes of Health Consensus Development Panel on Osteoporosis, Prevention, Diagnosis and Therapy. (2001). Osteoporosis prevention, diagnosis, and therapy. Journal of the American Medical Association, 285, 785–795. North American Menopause Society (2000). Consensus opinion: Clinical challenges of perimenopause. Menopause, 7(1), 5–13. Penckofer, S., & Schertz, D. (2001). Hormone replacement therapy: Primary and secondary prevention. Journal of Cardiovascular Nursing, 15(3), 1–25. Pilon, D., Castilloux, A., & Lelorier, J. (2001). Estrogen replacement therapy: Determinants of persistence with treatment. Obstetrics & Gynecology, 97(1), 97–100. Sawaya, G., Grady, D., Kerlikowske, K., et al. (2000). The positive predictive value of cervical smears in previously screened postmenopausal women: The heart and estrogen/progestin replacement study (HERS). Annals of Internal Medicine, 133(12), 942–950. *Schott-Baer, D., & Kotal, B. (2000). Frequency and effectiveness of self-care actions and menopause symptoms of middle-aged working women. MedSurg Nursing, 9(6), 302–308. Sharts-Hopko, N. C. (2001). Hysterectomy for nonmalignant conditions. American Journal of Nursing, 101(9), 32–40. Taylor, M. (2001). Psychological consequences of surgical menopause. Journal of Reproductive Medicine, 46(3 Suppl), 317–324, 333–336. Utian, W., & Boggs, P. (1999). The North American Menopause Society 1998 Menopause Survey. Part 1. Postmenopausal women’s perceptions about menopause and midlife. Menopause, 6, 122–128. Vandenakker, C. B., & Glass, D. D. (February 2001). Menopause and aging with disability. Physical and Medical Rehabilitation Clinics of North America, 12(1), 133–151. Writing Group for Women’s Health Initiative Investigators. (2002). Risks and benefits of estrogen plus progestin in healthy postmenopausal women: Principal results from the Women’s Health Initiative randomized controlled trial. Journal of the American Medical Association, 288(3), 321–333. Mutilation, Domestic Violence, Physical and Sexual Assault ACOG Committee on Gynecologic Practice and Committee on International Affairs. (1995). Female genital mutilation. ACOG Committee Opinion #151. ACOG (2000). Educational Bulletin #259. Adult manifestations of childhood sexual abuse. Clinical management guidelines for obstetricians-gynecologists. International Journal of Gynecology & Obstetrics, 74(3), 311–320.
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Assessment and Management of Female Physiologic Processes
Affara, F. (August 2000). When tradition maims. American Journal of Nursing, 100(8), 52–60. American Medical Association (AMA). Council on Scientific Affairs. (1995). Female genital mutilation: Council report. Jornal of the American Medical Association, 274(21), 1714–1716. Fourcroy, J. L. (1999). Female circumcision. American Family Physician, 60(2), 657–658. Garcia-Moreno, C. (2000). Violence against women: International perspectives. American Journal of Preventive Medicine, 19(4), 330–333. Kaplan, D., Feinstein, R., Fisher, M., et al. (2001). Care of the adolescent sexual assault victim. Pediatrics, 107(6), 1476–1479. Lampe, A., Solder, E., Ennemoser, A., et al. (2000). Chronic pelvic pain and previous sexual abuse. Obstetrics & Gynecology, 96(6), 929–932. *McFarlane, J., Soeken, K., & Wiist, W. (2000). An evaluation of interventions to decrease intimate partner violence to pregnant women. Public Health Nursing, 17(6), 443–451. Ng, F. (2000). Female genital mutilation: Its implications for reproductive health. An overview. British Journal of Family Planning, 26(1), 47–51. Salber, P., & McCaw, B. (2000). Barriers to screening for intimate partner violence: Time to reframe the question. American Journal of Preventive Medicine, 19(4), 276–278. Pap Smears ACOG Committee on Primary Care. (2000). Primary and preventive care: Periodic assessments. International Journal of Gynaecology & Obstetrics, 70(3), 393–399. ACOG Committee on Gynecology Practice Committee (2000). Routine cancer screening. Committee Opinion #247. Obstetrics & Gynecology, 96(6), insert 1–5. Association of Reproductive Health Professionals. (2002). Clinical update on transcervical sterilization. ARHP Clinical Proceedings, pp. 1–25. DeRemer Abercrombie, P. (2001). Improving adherence to abnormal Pap smear follow-up. Journal of Obstetric, Gynecologic and Neonatal Nursing, 30(1), 80–88. Franco, E., Duarte-Franco, E., & Ferenczy, A. (2001). Cervical cancer: Epidemiology, prevention and the role of human papillomavirus infection. Canadian Medical Association Journal, 164 (7), 1017–1025. Hopman, E. H., Rozendaal, L., Voorhorst, F. J., et al. (2000). High-risk human papillomavirus in women with normal cervical cytology prior to the development of abnormal cytology and colposcopy. British Journal of Obstetrics & Gynaecology, 107(5), 600–604. Sawaya, G. F., Brown, A. D., Washington, A. E., & Garber, A. M. (2001). Clinical practice. Current approaches to cervical-cancer screening. New England Journal of Medicine, 344(21), 1603–1607. Sawaya, G. F., Kerlikowske, K., Lee, N. C., et al. (2000). Frequency of cervical smear abnormalities within 3 years of normal cytology. Obstetrics & Gynecology, 96(2), 219–223. Solomon, D., Davey, D., Kurman, R., Moriarty, A., O’Connor, D., Prey, M., et al. (2001). The 2001 Bethesda System: Terminology for reporting results of cervical cytology. Consensus Statement. Journal of the American Medical Association, 287(16), 2114–2119. Sung, H., Kearny, K., Miller, M., et al. (2000). Papanicolaou smear history and diagnosis of invasive cervical carcinoma among members of a large prepaid health plan. Cancer, 88(10), 2283–2289. Wee, C., McCarthy, E., Davis, R., & Phillips, R. (2000). Screening for cervical and breast cancer: Is obesity an unrecognized barrier to preventive care? Annals of Internal Medicine, 132(9), 697–704. Wright, T. C., Jr., Cox, J. T., Massad, L. S., Twiggs, L. B., & Wilkinson, E. J. (2002). ASCCP-Sponsored Consensus Conference. 2001 Consensus Guidelines for the management of women with cervical cytological abnormalities. Journal of the American Medical Association, 287(16), 2120–2129.
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RESOURCES AND WEBSITES American College of Obstetricians and Gynecologists (ACOG), 409 12th St. SW, P.O. Box 96920, Washington, DC 20090-6920; http://www.acog.org. American Public Health Association and the Maternal Child Health Community Leadership Institute. Understanding the health culture of recent immigrants to the United States: a cross-cultural maternal health information catalog. 800 I Street, NW, Washington, DC 20001; (202) 777-2742; http://www.apha.org/ppp/maternal. Amnesty International, 322 Eighth Ave., New York, NY 10001 (212) 807-8400; http://www.amnesty.org/ailib/intcam/femgen/fgm10.htm (resource for activists to end female genital mutilation). Association of Women’s Health, Obstetrical and Neonatal Nurses (AWHONN, formerly NAACOG), 2000 L Street NW, Suite 740, Washington, DC 20036; (800) 673-8499; http://www.awhonn.org. American Society for Reproductive Medicine (ASRM), 209 Montgomery Highway, Birmingham, AL 35216; (205) 978-5000; http://www. asrm.org. Association of Reproductive Health Professionals, 2401 Pennsylvania Ave NW, Suite 350, Washington, DC 20037; (202) 466-3826; http://www.arhp.org. Department of Adolescent Health, American Medical Association, 515 North State St., Chicago, IL 60610; Adolescent Health on Line at http://www.ama-assn.org/ama/pub/category/1947.html. D.E.S. Action USA, 610 16th Street, Suite 301, Oakland, CA 94612; (510) 465-4011; http://www.desaction.org. Emergency Contraception; Office of Population Research, Princeton University, Princeton, NJ 08540; (888) Not-2-Late; http://opr. princeton. edu/ec. Family Violence Prevention Fund, 383 Rhode Island St., Suite 304, San Francisco, CA 94103; (415) 252-8900; http://www.fvpf.org. Female Genital Mutilation Education and Networking Project, http: // www.fgmnetwork.org; e-mail:
[email protected]. Healthy People 2010, http://www.health.gov/healthy people/Dept HHS (lists goals for health in 2010 and progress toward those goals). Jacob’s Institute of Women’s Health, 409 12th St SW, Washington, DC; (202) 863-4990; http://www.jiwh.org. National Coalition Against Domestic Violence, 503 Capitol Court, NE, Suite 300, Washington, DC 20002. National Association of Nurse Practitioners in Women’s Health (NPWH); (202) 543-9693; e-mail:
[email protected]; http://www. npwh.org/index.html. National Osteoporosis Foundation, 1150 17th St. NW, Suite 500, Washington, DC 20036; (800) 223-9994; e-mail:
[email protected].; http://www.not.org. North American Menopause Society, P.O. Box 94527, Cleveland, OH 44101; (800) 772-5342; http://www.menopause.org. Nursing Network on Violence Against Women International, 1801 H Street, Suite B5-165, Modesto, CA 95354; (888) 909-9993. Planned Parenthood Federation of America, 810 Seventh Ave., New York, NY 10019; (212) 541-7800; http://www.plannedparenthood.org. Research, Action and Information Network for the Bodily Integrity of Women (RAINBO), 915 Broadway, Suite 1109, New York, NY 10010-7108; (212) 477-3318; e-mail:
[email protected]; http://www.rainbo.org. Resolve National Headquarters, 1310 Broadway, Somerville, MA 02144; (617) 623-0744; e-mail:
[email protected]. http://www.resolve.org. Sexuality Information and Education Council of the United States, 130 W. 42nd St., Suite 350, New York, NY 10036; (212) 819-9770; http://www.siecus.org. World Health Organization Department of Women’s Health; 525 23 St. NW, Washington, DC 20037; (202) 974-3000; e-mail: whd@who. co; http://www.who.int/frh-whd/fgm/index.htm. Health Promotion for Women with Disabilities, Villanova University College of Nursing, 800 Lancaster Ave., Villanova, PA 19085; (610) 5194922; http://www.nursing.villanova.edu/WomenWithDisabilities.
Chapter
47 ●
Management of Patients With Female Reproductive Disorders
LEARNING OBJECTIVES
●
On completion of this chapter, the learner will be able to: 1. Compare the various types of vaginal infections and the signs, 2. 3. 4. 5. 6. 7. 8. 9.
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symptoms, and treatments of each. Develop a teaching plan for the patient with a vaginal infection. Use the nursing process as a framework for care of the patient with a vulvovaginal infection. Use the nursing process as a framework for care of the patient with genital herpes. Describe medical and nursing management for the patient with toxic shock syndrome. Discuss the signs and symptoms, management, and nursing care implications of malignant disorders of the female reproductive tract. Use the nursing process as a framework for care of the patient undergoing a hysterectomy. Describe indications for a wide excision of the vulva, or vulvectomy, and the preoperative and postoperative nursing interventions. Compare nursing interventions indicated for the patient undergoing radiation therapy and chemotherapy for cancer of the female reproductive tract.
D
Chapter 47
Management of Patients With Female Reproductive Disorders
isorders of the female reproductive system are relatively common. Some disorders are self-limited and cause only minor inconvenience to the woman; others are life-threatening and require immediate attention and long-term therapy. Many disorders are managed by the patient at home, whereas others require hospitalization and surgical intervention. All disorders require understanding and skill in patient teaching on the part of the nurse. The nurse must also be sensitive to women’s concerns and their possible, even probable, discomfort in discussing and dealing with these disorders.
Vulvovaginal Infections The vagina is protected against infection by its normally low pH (3.5 to 4.5), which is maintained in part by the actions of Lactobacillus acidophilus, the dominant bacteria in a healthy vaginal ecosystem. These bacteria suppress the growth of anaerobes and produce lactic acid, which maintains normal pH. They also produce hydrogen peroxide, which is toxic to anaerobes. The risk of infection rises if a woman’s resistance is reduced by stress or illness, if the pH is altered, or if a pathogen is introduced. Vulvovaginal infections are common problems, and nurses have an important role in providing information that may prevent their
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occurrence. To prevent these infections, women need to understand their own anatomy and vulvovaginal hygiene measures. In addition, continued research into causes and treatments is needed, along with better ways to encourage growth of lactobacilli. The epithelium of the vagina is highly responsive to estrogen, which induces glycogen formation. The subsequent breakdown of glycogen into lactic acid assists in producing a low vaginal pH. When estrogen decreases during lactation and menopause, glycogen also decreases. With reduced glycogen formation, infections may occur. In addition, as estrogen production ceases during the perimenopausal and postmenopausal periods, the vagina and labia may atrophy (thin), making the vaginal area more susceptible to infection. When patients are treated with antibiotics, the normal vaginal flora are reduced. This results in altered pH and growth of fungal organisms. Other factors that may initiate infections include sexual intercourse with an infected partner and wearing tight, nonabsorbent, and heat-retaining clothing (Chart 47-1). Vaginitis (inflammation of the vagina) occurs when Candida or Trichomonas species or other bacteria invade the vagina. The normal vaginal discharge, which may occur in slight amounts during ovulation or just before the onset of menstruation, becomes more profuse when vaginitis occurs. Urethritis may accompany
Glossary abscess: a collection of purulent material acquired immunodeficiency syndrome (AIDS): a disease transmitted by body fluids that results in impaired immune response Bartholin’s cyst: a cyst in a paired vestibular gland in the vulva brachytherapy: radiation delivered by an internal device placed close to the tumor candidiasis: infection caused by Candida species or yeast; also referred to as monilial vaginitis or yeast infection chancre: painless lesion caused by syphilis choriocarcinoma: a type of gestational neoplasm colporrhaphy: repair of the vagina condylomata: warty growths indicative of the human papillomavirus (HPV) conization: procedure in which a coneshaped piece of cervical tissue is removed as a result of detection of abnormal cells; also called cone biopsy cryotherapy: destruction of tissue by freezing (eg, with liquid nitrogen) cystocele: bulging of the bladder downward into the vagina dermoid cyst: ovarian tumor of undefined origin that consists of undifferentiated embryonal cells douche: rinsing the vaginal canal with fluid dysplasia: term related to abnormal cell changes found on Pap smear and cervical biopsy reports endocervicitis: inflammation of the mucosa and the glands of the cervix endometrial ablation: procedure performed through a hysteroscope in which the lining of the uterus is burned away or ablated to treat abnormal uterine bleeding
endometriosis: endometrial tissue in abnormal locations; causes pain with menstruation, scarring, and possible infertility fibroid tumor: usually benign tumor of the uterus that may cause irregular bleeding; also called myoma or leiomyoma fistula: abnormal opening between two organs or sites (ie, vesicovaginal, between bladder and vagina; rectovaginal, between rectum and vagina) hydatidiform mole: a type of gestational trophoblastic neoplasm hyphae: microscopic findings that indicate monilia hysterectomy: surgical removal of the uterus lactobacilli: vaginal bacteria that limit the growth of other bacteria by producing hydrogen peroxide laparoscope: surgical device inserted through a periumbilical incision to facilitate surgical visualization and procedures lichen sclerosus: benign disorder of the vulva that usually occurs when estrogen levels are low; characterized by itching liposomal therapy: chemotherapy delivered in a liposome, a nontoxic drug carrier loop electrocautery excision procedure (LEEP): procedure in which laser energy is used to remove a portion of cervical tissue after abnormal biopsy findings mucopurulent cervicitis (MCP): inflammation of the cervix with exudate; almost always related to a chlamydial infection myomectomy: removal of uterine fibroids though an abdominal incision oophorectomy: surgical removal of an ovary pelvic exenteration: major surgical procedure in which the pelvic organs are removed
pelvic inflammatory disease (PID): infection of uterus and fallopian tubes, usually from a sexually transmitted disease perineorrhaphy: surgical repair of perineal lacerations rectocele: bulging of the rectum into the vagina salpingo-oophorectomy: removal of the ovary and its fallopian tube (removal of the fallopian tube alone is a salpingectomy) salpingitis: inflammation of the fallopian tube toxic shock syndrome (TSS): a rare but potentially life-threatening infection caused by a toxin produced by Staphylococcus aureus; commonly associated with, but not exclusive to, use of superabsorbent tampons vaginal vault: term used to describe the vagina following a hysterectomy, which involves removal of the uterus including the cervix vaginitis: inflammation of the vagina, usually secondary to infection vestibulitis: inflammation of the vulvar vestibule, or tissue around the opening of the vagina, that causes pain often with intercourse (dyspareunia) vulvar dystrophy: thickening or lesions of the vulva; usually causes itching and may require biopsy to exclude malignancy vulvectomy: removal of the tissue of the vulva vulvitis: inflammation of the vulva, usually secondary to infection or irritation vulvodynia: painful condition that affects the vulva
Unit 10
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REPRODUCTIVE FUNCTION
Chart 47-1
Risk Factors for Vulvovaginal Infections Premenarche Pregnancy Perimenopause/Menopause Poor personal hygiene Tight undergarments Synthetic clothing Frequent douching Allergies Use of oral contraceptives Use of broad-spectrum antibiotics Diabetes mellitus Low estrogen levels Intercourse with infected partner Oral–genital contact (yeast can inhabit the mouth and intestinal tract) HIV infection
Table 47-1
vaginitis because of the proximity of the urethra to the vagina. Discharge that occurs with vaginitis may produce itching, odor, redness, burning, or edema, which may be aggravated by voiding and defecation. After the causative organism has been identified, appropriate treatment (discussed later) is prescribed. This may include oral medication or local medication that may be inserted into the vagina using an applicator.
CANDIDIASIS Vulvovaginal candidiasis is a fungal or yeast infection caused by strains of Candida (Table 47-1). Candida albicans accounts for most cases, but other strains, such as Candida glabrata, may also be implicated. Many women with a healthy vaginal ecosystem harbor Candida but are asymptomatic. Certain conditions favor the change from an asymptomatic state to colonization with symptoms. For example, use of antibiotics decreases bacteria, thereby altering the natural protective organisms usually present in the vagina. Clinical infection may occur during pregnancy, with a systemic condition such as diabetes mellitus or human
• Vaginal Infections and Vaginitis
INFECTION
CAUSE
CLINICAL MANIFESTATIONS
MANAGEMENT STRATEGIES
Candidiasis
Candida albicans, glabrata, or tropicalis
Inflammation of vaginal epithelium, producing itching, reddish irritation White, cheeselike discharge clinging to epithelium
Gardnerellaassociated bacterial vaginosis
Gardnerella vaginalis and vaginal anaerobes
Trichomonas vaginalis vaginitis (STD)
Trichomonas vaginalis
Bartholinitis (infection of greater vestibular gland)
Escherichia coli Trichomonas vaginalis Staphylococcus Streptococcus Gonococcus Chlamydia Gonorrhea Streptococcus Many pathogenic bacteria
Usually no edema or erythema of vulva or vagina Gray-white to yellow-white discharge clinging to external vulva and vaginal walls Inflammation of vaginal epithelium, producing burning and itching Frothy yellow-white or yellow-green vaginal discharge Erythema around vestibular gland Swelling and edema Abscessed vestibular gland
Eradicate the fungus by administering an antifungal agent. Frequently used brand names of vaginal creams and suppositories are Monistat, Femstat, Terazol, and Gyne-Lotrimin. Review other causative factors (eg, antibiotic therapy, nylon underwear, tight clothing, pregnancy, oral contraceptives). Assess for diabetes and HIV infection in patients with recurrent monilia. Administer metronidazole (Flagyl), with instructions about avoiding alcohol while taking this medication. If infection is recurrent may treat partner. Relieve inflammation, restore acidity, and reestablish normal bacterial flora; provide oral metronidazole for patient and partner.
Cervicitis: acute and chronic
Atrophic vaginitis
Lack of estrogen; glycogen deficiency
Profuse purulent vaginal discharge Backache Urinary frequency and urgency
Discharge and irritation with alkaline pH of vaginal secretions
Drain the abscess; provide antibiotic therapy; excise gland of patients with chronic bartholinitis.
Determine the cause: perform cytologic examination of cervical smear and appropriate cultures. Eradicate the gonococcal organism, if present: penicillin (as directed) or spectinomycin or tetracycline, if patient is allergic to penicillin. Tetracycline, doxycycline (Vibramycin) to eradicate chlamydia. Eradicate other causes. Provide topical vaginal estrogen therapy; improve nutrition if necessary; relieve dryness through use of moisturizing medications.
Chapter 47
Management of Patients With Female Reproductive Disorders
immunodeficiency virus (HIV) infection, or in a patient taking corticosteroids or oral contraceptives.
Clinical Manifestations Clinical manifestations include a vaginal discharge that causes pruritus (itching) and subsequent irritation. The discharge may be watery or thick but has a white, cottage cheese-like appearance. Symptoms are usually more severe just before menstruation and are usually less responsive to treatment during pregnancy. Diagnosis is made by microscopic identification of spores and hyphae on a glass slide prepared from a discharge specimen mixed with potassium hydroxide. With candidiasis, the pH is 4.5 or less.
Medical Management The goal of management is to eliminate symptoms. Treatments include antifungal agents such as miconazole (Monistat), nystatin (Mycostatin), clotrimazole (Gyne-Lotrimin), and terconazole (Terazol) cream. These agents are inserted into the vagina with an applicator at bedtime and may be applied to the vulvar area for pruritus. There are 1-night, 3-night, or 7-night treatment courses available. Oral medication is also available (fluconazole [Diflucan]). Fluconazole is given in a one-pill dose; relief should be noted within 3 days. Vaginal creams are available without a prescription; however, patients are cautioned to use these creams only if they are certain that they have a yeast or monilial infection. Many patients use these remedies for problems other than yeast infections. If the patient is uncertain about the cause of her symptoms or has not obtained relief after using these creams, she is instructed to seek health care promptly. Yeast infections can sometimes become recurrent and may be related to cell-mediated immunity or to an allergic response. Women with recurrent yeast infections benefit from a comprehensive gynecologic workup.
SEMINAL PLASMA PROTEIN ALLERGY Women with this condition develop an immunologic response to human semen, resulting in vaginal inflammation. Symptoms vary from local inflammation and pruritus to rare systemic anaphylaxis after exposure. Diagnosis is usually based on the absence of symptoms with condom use. Treatment may include cromolyn vaginal cream and immunotherapy. The success rate of treatment varies, and referral to an immunologist may be warranted.
BACTERIAL VAGINOSIS Bacterial vaginosis is caused by an overgrowth of anaerobic bacteria and Gardnerella vaginalis normally found in the vagina and an absence of lactobacilli (see Table 47-1). It is characterized by a fish-like odor that is particularly noticeable after sexual intercourse or during menstruation as a result of a rise in the vaginal pH. It is usually accompanied by a heavier-than-normal discharge. Risk factors include douching, smoking, and increased sexual activity. Bacterial vaginosis can occur throughout the menstrual cycle and does not produce local discomfort or pain. More than half of women with bacterial vaginosis do not notice any symptoms. Discharge, if noticed, is gray to yellowish white. The fish-like odor can be detected readily by adding a drop of potassium hydroxide to a glass slide with a sample of vaginal discharge, which releases amines. Under the microscope, vaginal cells are coated
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with bacteria and are described as “clue cells.” The pH of the discharge is usually above 4.7 because of the amines that result from enzymes from anaerobes. Lactobacilli, a natural host defense, are usually absent. Bacterial vaginosis is usually not a serious condition, but it has been associated with premature labor, endometritis, and recurrent urinary tract infection.
Medical Management Metronidazole (Flagyl), administered orally twice a day for 1 week, is effective; a vaginal gel is also available. Clindamycin (Cleocin) vaginal cream or ovules (oval suppositories) are also effective. If the infection recurs, the patient’s partner may require treatment. Patients with recurrent bacterial vaginosis should be tested for gonorrhea and chlamydia.
TRICHOMONIASIS Trichomonas vaginalis is a flagellated protozoan that causes a common, usually sexually transmitted vaginitis that is often called “trich.” About 5 million cases occur each year in the United States (U.S. Surgeon General’s Report, 2001). It may be transmitted by an asymptomatic carrier who harbors the organism in the urogenital tract (see Table 47-1). It may increase the risk of contracting HIV from an infected partner.
NURSING RESEARCH PROFILE 47-1
Vaginal Infections in Abused Versus Nonabused Pregnant Hispanic Women King., E. A., Britt, R., McFarlane, J. M., & Hawkins, C. (2000). Bacterial vaginosis and Chlamydia trachomatis among pregnant abused and nonabused Hispanic women. JOGNN, 29(6), 606–612.
Purpose The purpose of this study was to examine the prevalence of bacterial vaginosis (BV) and Chlamydia trachomatis (CT) in a cohort of abused and nonabused pregnant Hispanic women. Study Sample and Design The sample consisted of 233 pregnant, abused Hispanic women and 468 pregnant, nonabused Hispanic women from three urban prenatal clinics of a public health department in the southwestern United States. The women’s status regarding abuse (abused vs. nonabused) was determined for a previous study by self-report using the Abuse Assessment Screen. Chart review was undertaken to determine the prevalence of BV and CT in both groups. Evidence of BV and CT in the women’s medical records was based on standard ACOG criteria. Findings The combined prevalence of BV and CT in the group of abused women was significantly higher ( p < .05) than that for nonabused women. There was no difference in prevalence of CT alone, but the prevalence of BV was significantly higher ( p < .05) for abused women. There were no significant differences in the two groups in terms of marital status, age, gestational age, or number of prenatal visits. Nursing Implications Although the findings are limited to one ethnic group in an urban public clinic setting, they do suggest the need for targeted screening of all abused pregnant women for BV. Detection and treatment of women with BV may prevent premature rupture of membranes and premature delivery in this high-risk group of pregnant women.
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Clinical Manifestations Clinical manifestations include a vaginal discharge that is thin (sometimes frothy), yellow to yellow-green, malodorous, and very irritating. An accompanying vulvitis may result, with vulvovaginal burning and itching. Diagnosis is made by microscopic detection of the pear-shaped, mobile, flagellate organisms. Inspection with a speculum often reveals vaginal and cervical erythema (redness) with multiple small petechiae (“strawberry spots”). pH testing of a trichomonal discharge will demonstrate a pH greater than 4.5.
Medical Management The most effective treatment for trichomoniasis is metronidazole (Flagyl). Both partners receive a one-time loading dose or a smaller dose three times a day for 1 week. The one-time dose is more convenient; consequently, compliance tends to be greater. The weeklong treatment has occasionally been noted to be more effective. Some patients complain of an unpleasant but transient metallic taste when taking metronidazole. Nausea and vomiting, as well as a hot, flushed feeling, occur when this medication is taken with an alcoholic beverage (disulfiram-like reaction). In view of these side effects, the patient is strongly advised to abstain from alcohol while taking the medication. Metronidazole therapy is contraindicated in patients with some blood dyscrasias or central nervous system diseases, in the first trimester of pregnancy, and in women who are breastfeeding. It is not prescribed without examination. Gerontologic Considerations After menopause, the vaginal mucosa becomes thinner and may atrophy. This condition can be complicated by infection from pyogenic bacteria, resulting in atrophic vaginitis (see Table 47-1). Leukorrhea (vaginal discharge) may cause itching and burning. Management is similar to that for bacterial vaginosis if bacteria are present. Estrogenic hormones, either taken orally or inserted into the vagina in a cream form, can also be effective in restoring the epithelium.
• • • •
soaps, bubble bath, poor hygiene, and use of feminine hygiene products Psychogenic factors (eg, stress, fear of STDs, abuse) Medical conditions or endocrine factors, such as a predisposition to vulvar involvement in a patient who has diabetes or is elderly Use of medications such as antibiotics, which may alter the vaginal flora and allow an overgrowth of monilial organisms New sex partner, multiple sex partners, previous vaginal infection
The patient is also asked about other factors that could contribute to infection, including hygiene practices (tampons, douching), use or nonuse of condoms, and use of chemicals such as nonoxynol-9 with barrier methods of birth control. The nurse may prepare a vaginal smear (wet mount) to assist in diagnosing the infection. A common method for preparing the smear is to collect vaginal secretions with an applicator and place the secretions on two separate glass slides. A drop of saline solution is added to one slide and a drop of 10% potassium hydroxide is added to another slide for examination under a microscope. If bacterial vaginosis is present, the slide with normal saline solution added shows epithelial cells dotted with bacteria (clue cells). If Trichomonas species is present, small motile cells are seen. In the presence of yeast, the potassium hydroxide slide reveals typical characteristics. Discharge associated with bacterial vaginosis produces a strong odor when mixed with potassium hydroxide. This is called a positive “whiff test.” Testing the pH of the discharge with Nitrazine paper assists in proper diagnosis.
Diagnosis NURSING DIAGNOSES Based on the nursing assessment and other data, the patient’s major nursing diagnoses may include the following:
• Discomfort related to burning, odor, or itching from the infectious process
• Anxiety related to stressful symptoms • Risk for infection or spread of infection • Deficient knowledge about proper hygiene and preventive measures
NURSING PROCESS: THE PATIENT WITH A VULVOVAGINAL INFECTION Assessment The woman with vulvovaginal symptoms should be examined as soon as possible after the onset of symptoms. She is instructed not to douche because doing so removes the vaginal discharge needed to make the diagnosis. The area is observed for erythema, edema, excoriation, and discharge. Each of the infection-producing organisms produces its own characteristic discharge and effect (see Table 47-1). The patient is asked to describe any discharge and other symptoms, such as odor, itching, or burning. Dysuria often occurs as a result of local irritation of the urinary meatus. A urinary tract infection may need to be ruled out by obtaining a urine specimen for culture and sensitivity testing. The patient is asked about the occurrence of factors that may contribute to vulvovaginal infection:
• Physical and chemical factors, such as constant moisture from tight or synthetic clothing, perfumes and powders,
Planning and Goals The major goals for the patient may include relief of discomfort, reduction of anxiety related to stress symptoms, prevention of reinfection or infection of sexual partner, and acquisition of knowledge about methods for preventing vulvovaginal infections and managing self-care.
Nursing Interventions RELIEVING DISCOMFORT Treatment with the appropriate medication usually relieves discomfort. Sitz baths are occasionally recommended. Use of cornstarch powder may relieve discomfort and skin irritation. REDUCING ANXIETY Although vulvovaginal infections are upsetting and require treatment, they are not life-threatening. The patient who experiences such an infection, however, may be anxious and fearful about the significance of the symptoms and possible causes. Explaining the cause of symptoms may reduce anxiety related to fear of a more
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serious illness. Discussing ways to help prevent vulvovaginal infections may help the patient adopt specific strategies to decrease infection and the related symptoms. PREVENTING REINFECTION OR SPREAD OF INFECTION There is a risk of another episode of the same infection or spread of the infection to sexual partners. The patient needs to be informed about these risks and the importance of adequate treatment of herself and her partner, if indicated. Other strategies to prevent persistence or spread of infection include abstaining from sexual intercourse when infected, treatment of sexual partners, and minimizing irritation of the affected area. When medications such as antibiotic agents are prescribed for any infection, the nurse instructs the patient about the usual precautions related to using these agents. If vaginal itching occurs, the patient can be reassured that this is usually not an allergic reaction but may be a yeast or monilial infection resulting from altered vaginal bacteria. Treatment for monilial infection is prescribed. Another goal of treatment is to reduce tissue irritation caused by scratching or wearing tight clothing. The area needs to be kept clean by daily bathing and adequate hygiene after voiding and defecation. The use of a cool-air hairdryer and application of topical corticosteroids may be useful to keep the area dry and minimize irritation. When teaching the patient about medications such as suppositories and devices such as applicators to dispense cream or ointment, the nurse may demonstrate the procedure by using a plastic model of the pelvis and vagina. The nurse should also stress the importance of hand washing before and after each administration of medication. To prevent the medication from escaping from the vagina, the patient should recline for 30 minutes after it is inserted, if possible. The patient is informed that seepage of medication may occur, and the use of a perineal pad may be helpful. PROMOTING HOME AND COMMUNITY-BASED CARE Teaching Patients Self-Care Vulvovaginal conditions are treated on an outpatient basis, unless the patient has other medical problems. Patient teaching, tact, and reassurance are important aspects of nursing care. Women may express embarrassment, guilt, or anger and may be concerned that the infection may be serious (causing infertility) or that it may have been acquired from a sex partner. In some instances, treatment plans include the partner. In addition to reviewing ways of relieving discomfort and preventing reinfection, the nurse assesses each patient’s learning needs relative to the immediate problem. The patient needs to know the characteristics of normal as opposed to abnormal discharge. Questions often arise about douching. Normally, douching and use of feminine hygiene sprays are unnecessary because daily baths or showers and proper hygiene after voiding and defecating keep the perineal area clean. Douching tends to eliminate normal flora, reducing the body’s ability to ward off infection. In addition, repeated douching may result in vaginal epithelial breakdown and chemical irritation and has been associated with other pelvic disorders. Therapeutic douching, however, may be recommended and prescribed to reduce unpleasant, abnormal odors; to remove excessive discharge; to change the pH (eg, vinegar douches); and to serve as an antiseptic irrigating solution. The procedure is reviewed with the patient, as is the care and cleaning of equipment so that it is properly disinfected.
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In the case of recurrent yeast infections, the perineum should be kept as dry as possible. Loose-fitting cotton instead of tightfitting synthetic, nonabsorbent, heat-retaining underwear is recommended. The patient is instructed to perform a monthly inspection of the vulvar region for changes.
Evaluation EXPECTED PATIENT OUTCOMES Expected patient outcomes may include: 1. Experiences reduced discomfort a. Cleans the perineum as instructed b. Reports that itching is relieved c. Maintains urine output within normal limits and without dysuria 2. Experiences relief of anxiety 3. Remains free from infection a. Has no signs of inflammation, pruritus, odor, or dysuria b. Notes that vaginal discharge appears normal (thin, clear, not frothy) 4. Participates in self-care a. Takes medication as prescribed b. Wears absorbent underwear c. Avoids unprotected sexual intercourse d. Douches only as prescribed
HUMAN PAPILLOMAVIRUS Human papillomavirus (HPV) infection is sexually transmitted and is the most common sexually transmitted disease (STD) among young, sexually active persons. An estimated 5.5 million people become infected with HPV each year in the United States (U.S. Surgeon General’s Report, 2001). More than 80 strains exist, some of which are associated with cervical abnormalities, including dysplasia and cancer. Infections can be latent (asymptomatic and detected only by DNA hybridization tests for HPV), subclinical (visualized only after application of acetic acid followed by inspection under magnification), or clinical (visible condylomata acuminata). The most common strains, 6 and 11, usually cause condylomata (warty growths) on the vulva. These are often visible or may be palpable by the patient. Condylomata are rarely premalignant but are an outward manifestation of the virus. Strains 6 and 11 are associated with a low risk for cervical cancer. Some strains may not cause condylomata but affect the cervix, resulting in abnormal Pap smear results. For example, strains 16, 18, 31, 33, 35, and 45 affect the cervix. Their effects are usually invisible on examination but may be seen on colposcopy. They may cause cervical changes that may appear as koilocytosis on Pap smear or abnormal smear results. These strains are associated with a higher risk for cervical cancer (U.S. Surgeon General’s Report, 2001). The incidence of HPV in young, sexually active women is high. Risk factors include being sexually active, having multiple sex partners, and having sex with a partner who has or has had multiple partners. Alcohol consumption and drug use are risk factors, as both impair careful decision making, judgment, and selfcare (Association of Reproductive Health Practitioners, 2001).
Medical Management Treatment of external genital warts includes topical application of trichloroacetic acid, podophyllin (Podofin, Podocon), and chemotherapeutic agents. Interferon injections are also used in
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treatment. These agents are applied by the health care provider. Topical agents that can be applied by the patient to external lesions include podofilox (Condylox) and imiquimod (Aldara). Because the safety of podophyllin, imiquimod, and podofilox during pregnancy has not been determined, these agents should not be used to treat pregnant women. Electrocautery and laser therapy are alternative therapies that may be indicated for patients with a large number or area of genital warts (Centers for Disease Control & Prevention, 2002). Treatment usually eradicates perineal warts or condylomata. However, they may resolve spontaneously without treatment and may also recur even with treatment. If the treatment includes application of the topical agent by the patient, she needs to be carefully instructed in the use of the agent prescribed and must be able to identify the warts and be able to apply the medication to them. The patient is instructed to anticipate mild pain or local irritation with the use of these agents (Centers for Disease Control & Prevention, 2002). Patients with HPV should have regular Pap smears, possibly every 6 months for several years, because of the propensity of HPV to cause dysplasia (changes in cervical cells). Much remains unknown about the subclinical disease and latent phase of the disease. Women are often exposed to this virus by a partner who is unknowingly a carrier. Condoms can prevent transmission, but transmission can also occur during skin-to-skin contact in areas not covered by condoms. In many cases, patients are angry about having warts or HPV and do not know who infected them because the incubation period can be long and partners may have no symptoms. Acknowledging the emotional distress that occurs when an STD is diagnosed and providing support and facts are important nursing actions.
HERPESVIRUS TYPE 2 INFECTION (HERPES GENITALIS, HERPES SIMPLEX VIRUS) Herpes genitalis is a recurrent, life-long viral infection that causes herpetic lesions (blisters) on the cervix, vagina, and external genitalia. It is an STD but may also be transmitted asexually from wet surfaces or by self-transmission (ie, touching a cold sore and then touching the genital area). The initial infection is usually very painful and lasts about 1 week, but it can also be asymptomatic. Recurrences are less painful and usually produce minor itching and burning. Some patients have few or no recurrences, whereas others have frequent bouts. Recurrences are often associated with stress, sunburn, dental work, or inadequate rest or nutrition. The incidence of herpes infection has increased fivefold since the late 1970s among Caucasian teenagers and adults in their 20s. At least 50 million persons in the United States have genital herpes infection; most of them have not been diagnosed (Centers for Disease Control & Prevention, 2002). The prevalence of other STDs has decreased slightly, possibly due to increased condom use, but herpes can be transmitted by contact with skin not covered by a condom. Transmission is possible even when the carrier does not have symptoms (subclinical shedding). Lesions increase vulnerability to HIV infection and other STDs. Vaccines for this virus are in clinical trials.
zoster, or shingles; (4) Epstein-Barr virus; (5) cytomegalovirus; and (6) human B-lymphotrophic virus. HSV-2 appears to be the cause of about 80% of genital and perineal lesions; HSV-1 may cause about 20%. There is considerable overlap between HSV-1 and HSV-2, which are clinically indistinguishable. Close human contact by the mouth, oropharynx, mucosal surface, vagina, or cervix appears necessary to acquire the infection. Other susceptible sites are skin lacerations and conjunctivae. Usually, the virus is killed at room temperature by drying. When viral replication diminishes, the virus ascends the peripheral sensory nerves and remains inactive in the nerve ganglia. Another outbreak may occur when the host is subjected to stress. In pregnant women with active herpes, babies delivered vaginally may become infected with the virus. There is a risk for fetal morbidity and mortality if this occurs; therefore, a cesarean delivery may be performed if the virus recurs near the time of delivery.
Clinical Manifestations Itching and pain accompany the process as the infected area becomes red and swollen (edematous). The vesicular state often appears as a blister, which later coalesces, ulcerates, and encrusts. In women, the labia are the usual primary site, although the cervix, vagina, and perianal skin may be affected. In men, the glans penis, foreskin, or penile shaft is typically affected. Influenza-like symptoms may occur 3 or 4 days after the lesions appear. Inguinal lymphadenopathy (swollen lymph nodes in the groin), minor temperature elevation, malaise, headache, myalgia (aching muscles), and dysuria (pain on urination) are often noted. Pain is evident during the first week and then decreases. The lesions subside in about 2 weeks unless secondary infection occurs. Rarely, complications may arise from extragenital spread, such as to the buttocks, upper thighs, or even the eyes as a result of touching lesions and then touching other areas. Patients should be advised to wash their hands after contact with lesions. Other potential problems are aseptic meningitis and severe emotional stress related to the diagnosis.
Medical Management There is currently no cure for HSV-2 infection, but treatment is aimed at relieving the symptoms. Management goals are preventing the spread of infection, making the patient comfortable, decreasing potential health risks, and initiating a counseling and education program. Acyclovir (Zovirax), valacyclovir (Valtrex), and famciclovir (Famvir) are antiviral agents that can suppress symptoms and shorten the course of the infection. Other antiviral agents are also available. All of them are effective at reducing the duration of lesions and preventing recurrences. Resistance and long-term side effects do not appear to be major problems. Recurrent episodes are much milder than the initial episode.
NURSING PROCESS: THE PATIENT WITH A GENITAL HERPESVIRUS INFECTION Assessment
Pathophysiology Of the known herpesviruses, six affect humans: (1) herpes simplex type 1 (HSV-1), which usually causes cold sores of the lips; (2) herpes simplex type 2 (HSV-2), or genital herpes; (3) varicella
The health history and a physical and pelvic examination are important in establishing the nature of the infectious condition. Additionally, the patient is assessed for risk for STDs. The perineum is inspected for painful lesions. Inguinal nodes are
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assessed because they often are enlarged and tender during an occurrence of HSV.
nurse can refer the patient to a support group to assist in coping with the diagnosis (see Resources at the end of the chapter).
Diagnosis
INCREASING KNOWLEDGE ABOUT THE DISEASE AND ITS TREATMENT Patient teaching is an essential part of nursing care of the patient with a genital herpes infection. This includes an adequate explanation about the infection and how it is transmitted, management and treatment strategies, strategies to minimize spread of infection, the importance of adherence to the treatment regimen, and self-care strategies. Because of the increased risk of HIV and other STDs in the presence of skin lesions, an important part of patient education involves instructing the patient to protect herself from exposure to HIV and other STDs. Further details are included in Chart 47-2.
NURSING DIAGNOSES Based on the assessment data, the patient’s major nursing diagnoses may include the following:
• • • •
Acute pain related to the genital lesions Risk for infection or spread of infection Anxiety related to the diagnosis Deficient knowledge about the disease and its management
Planning and Goals The major goals for the patient may include relief of pain and discomfort, control of infection and its spread, relief of anxiety, knowledge of and adherence to the treatment regimen and selfcare, and knowledge about implications for the future.
Nursing Interventions RELIEVING PAIN The lesions should be kept clean, and proper hygiene practices are advocated. Sitz baths ease discomfort. Clothing should be clean, loose, soft, and absorbent. Aspirin and other analgesics are usually effective in controlling pain. Occlusive ointments and powders are avoided because they prevent the lesions from drying. If there is considerable pain and malaise, bed rest may be required. The patient is encouraged to increase fluid intake, to be alert for possible bladder distention, and to contact her primary health care provider immediately if she cannot void because of discomfort. Painful voiding may occur if urine comes in contact with the herpes lesions. Discomfort with urination can be reduced by pouring warm water over the vulva during voiding or by sitz baths. When oral acyclovir or other antiviral agents are prescribed, the patient is instructed about when to take the medication and what side effects to note, such as rash and headache. Rest, fluids, and a nutritious diet are recommended to promote recovery. PREVENTING INFECTION AND ITS SPREAD The risk of reinfection and spread of infection to others or to other structures of the body can be reduced by hand washing, use of barrier methods with sexual contact, and adherence to prescribed medication regimens. Avoidance of contact when obvious lesions are present does not eliminate the risk because the virus can be shed in the absence of symptoms, and lesions may not be visible to the woman. Avoiding stress, sunburn, and other stress-producing situations may decrease the episodes of recurrence. RELIEVING ANXIETY Concern about the presence of herpes infection, future occurrences of lesions, and the impact of the infection on future relationships and childbearing may cause considerable anxiety in the patient. The nurse can be an important support, listening to the patient’s concerns and providing information and instruction. The patient may be angry with her partner if her partner is the probable source of the infection. She may need assistance and support in discussing the infection and its implications with her current sexual partner and in future sexual relationships. The
PROMOTING HOME AND COMMUNITY-BASED CARE Teaching Patients Self-Care Genital herpes causes physical pain and emotional distress. Usually, the patient is upset on learning the diagnosis. Therefore, when counseling the patient, the nurse should explain the causes of the condition and the manner in which it can be managed. Questions are encouraged because they may indicate that the patient is receptive to learning. The nurse can provide reassurance that the lesions will heal and that recurrences can be minimized by adopting a healthful lifestyle and by taking prescribed medications. Self-care measures for the person with genital herpes appear in Chart 47-2.
Evaluation EXPECTED PATIENT OUTCOMES Expected patient outcomes may include: 1. Experiences a reduction in pain and discomfort 2. Keeps infection under control a. Demonstrates proper hygiene techniques b. Takes medication as prescribed c. Consumes adequate fluids d. Adopts healthy lifestyle (diet, adequate fluid intake, safer sex practices, stress management) 3. Uses strategies to reduce anxiety a. Verbalizes issues and concerns related to genital herpes infection b. Discusses strategies to deal with issues and concerns with current and future sexual partner c. Initiates contact with support group if indicated 4. Demonstrates knowledge about genital herpes and strategies to control and minimize recurrences a. Identifies methods of transmission of herpes infection and strategies to prevent transmission to others b. Discusses strategies to reduce recurrence of lesions c. Takes medications as prescribed d. Reports no recurrence of lesions
TOXIC SHOCK SYNDROME Toxic shock syndrome (TSS) is a life-threatening, multisystem disease caused by response to the toxins produced by strains of the bacterium S. aureus in susceptible patients. This rare condition is associated with menstruation (although the incidence of menstrual TSS has dramatically decreased due to public awareness, the number of nonmenstrual cases of TSS has not declined).
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Chart 47-2 Home Care Checklist • The Patient With Genital Herpes At the completion of the home care instruction, the patient or caregiver will be able to: • State that herpes is transmitted mainly by direct contact. • State that abstinence from sex is required for a brief period (intercourse is avoided during treatment, but other options such as hand-holding and kissing are acceptable). • State that intercourse during a herpes outbreak not only increases the risk of transmission but also increases the likelihood of contracting HIV and other STDs. • State that transmission is possible even in the absence of active lesions. • State that condoms may provide some protection against viral transmission. • Explain that obstetric care provider should be informed about the history of herpes. In cases of recurrence at time of delivery, cesarean section may be considered. • Describe appropriate hygiene practices (hand washing, perineal cleanliness, gentle washing of lesions with mild soap and running water and lightly drying lesions) and importance of avoiding occlusive ointments, strong perfumed soaps, or bubble bath. • State that control of the condition may require changes in sexual behavior and use of medications. • Describe strategies to avoid self-infection (ie, avoid touching lesions during an outbreak). • Explain rationale for avoiding self-infection (ie, lesions can become infected from germs on the hand, and the virus from the lesion can be transmitted from the hand to another area of the body or another person). • Describe health promotion strategies: wear loose, comfortable clothing; eat a balanced diet; get adequate rest and relaxation. • State rationale for avoiding exposure to the sun; can cause recurrences (and skin cancer). • Identify importance of taking medications as prescribed, keeping follow-up appointments with health care provider, and reporting repeated recurrences (may not be as severe as the initial episode). • Describe possible benefits of joining a group to share solutions and experiences and hear about newer treatments, such as HELP (Herpetics Engaged in Living Productively).
Approximately 1% of women carry strains of staphylococcus capable of producing the responsible toxin. Nonmenstrual TSS occurs after childbirth, after abortion, and in persons with bone and skin infections, postoperative infections, burns, mastitis, and varicella-related cellulitis. Sinusitis, tracheitis, pneumonia, and the presence of foreign bodies (eg, nasal packing, IUDs, contraceptive sponges) have been associated with nonmenstrual TSS.
Clinical Manifestations In an otherwise healthy person, the onset of TSS occurs with a sudden fever (temperature is always at least 38.9° C [102° F]), chills, malaise, and muscle pain. Vomiting, diarrhea, hypotension, headache, and signs suggesting early septic shock may develop. A red, macular rash similar to sunburn (diffuse, macular erythroderma) is a classic sign of TSS. In some patients, this rash appears first on the torso; in others, it is first seen on the hands (palms and fingers) and feet (soles and toes). Inflammation of mucous membranes also may occur. In 7 to 10 days, it desquamates (becomes scaly or peels). Myalgia and dizziness are common. Severe cases can result in acute respiratory distress syndrome (ARDS), and cardiac dysfunction may occur.
Assessment and Diagnostic Findings Urine output decreases, and the blood urea nitrogen level increases, often resulting in disorientation. Laboratory tests also reveal leukocytosis and elevated bilirubin. Uncontrollable hypotension and disseminated intravascular coagulopathy (DIC) may also occur. The clinical picture of septic shock (described in Chap. 15) results. Respiratory distress may develop as a result of pulmonary edema. If ARDS occurs, the outlook is grave. About 2% to 3% of patients with TSS die of complications.
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Medical Management Treatment includes elimination of the source of the infection; administration of fluids, vasopressors, and antibiotic agents; and irrigation of the presumed site of infection. The patient is placed on bed rest, and the treatment plan is directed primarily at controlling the infection and restoring circulating blood volume. Antibiotic therapy is based on the results of blood, urine, and other cultures. Antistaphylococcal agents are prescribed. Antibiotic therapy has not been found to affect the course of TSS but to prevent recurrence. In cases of respiratory distress, oxygen therapy is instituted; if signs of acidosis appear, sodium bicarbonate is administered. Calcium is prescribed for hypocalcemia. A Swan-Ganz catheter (for hemodynamic monitoring) and intravenous dopamine may be used to manage shock. The entire treatment plan, including strategies directed toward emotional and psychological concerns, is adjusted according to each patient’s condition, which may vary from mild to acute.
Nursing Management The patient with suspected TSS is assessed for factors known to be associated with it: use of tampons (absorbency, length of time a tampon was retained before changing it, trauma that may have occurred with its insertion) or diaphragms and the presence of other risk factors. Additionally, the patient is assessed and treated for complications associated with TSS (DIC and septic shock). The patient is observed for hematomas, petechiae, oozing from needle and infusion sites, cyanosis, and coolness of the nose, fingertips, and toes. The patient is further observed for skin changes and fluid intake and loss; these data assist in evaluating hydration and kidney function. The patient with TSS is usually critically ill
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and is cared for in the intensive care unit to facilitate constant monitoring and assessment for the onset of complications and response to treatment. Because of the likelihood of severe septic shock, the patient is monitored closely for changes in vital signs, level of consciousness and responsiveness to stimuli, and laboratory values, including arterial blood gases. The patient’s response to prescribed medications and fluids is also evaluated. See Chapter 15 for more information about management of shock. Teaching Patients Self-Care. Because of the lengthy period that is required for recovery from TSS, the patient must be prepared to increase participation in self-care activities gradually. The patient and caregiver need instructions about detection and prevention of the complications associated with immobility. The nurse also explains the possible causes of TSS and steps to take to prevent its recurrence. Because use of tampons during menstruation has been linked with TSS, women who have had TSS should not use tampons. If a diaphragm is used, it should not be left in place longer than 8 to 10 hours. Using the diaphragm or cervical cap during menses or in the first 3 months postpartum is also discouraged. The risk of developing TSS increases any time a woman bleeds vaginally (ie, during menses and postpartum). Because of the risk of TSS, all women who use tampons should be informed that they must be changed frequently (every 4 hours) and inserted carefully to avoid abrasions (applicators with rough edges should be avoided). Use of superabsorbent tampons is not recommended.
ENDOCERVICITIS AND CERVICITIS Endocervicitis is an inflammation of the mucosa and the glands of the cervix that may occur when organisms gain access to the cervical glands after intercourse and, less often, after procedures such as abortion, intrauterine manipulation, or vaginal delivery. If untreated, the infection may extend into the uterus, fallopian tubes, and pelvic cavity. Inflammation can irritate the cervical tissue, resulting in spotting or bleeding and mucopurulent cervicitis.
CHLAMYDIA AND GONORRHEA Chlamydia and gonorrhea are the most common causes of endocervicitis, although Mycoplasma may also be involved. Chlamydia causes about 3 million infections every year in the United States; it is most commonly found in young, sexually active people with more than one partner and is transmitted through sexual intercourse (U.S. Surgeon General’s Report, 2001). It can result in serious complications, including pelvic infection, an increased risk for ectopic pregnancy, and infertility. Up to 40% of untreated women develop pelvic inflammatory disease (PID). One in 20 women of reproductive age in the United States is infected. Chlamydial infections of the cervix often produce no symptoms, but cervical discharge, dyspareunia, dysuria, and bleeding may occur. Other complications include conjunctivitis and perihepatitis. If a pregnant woman is infected, stillbirth, neonatal death, and premature labor may occur. Infants born to infected mothers may experience prematurity, conjunctivitis, and pneumonia. Chlamydial infection and gonorrhea often coexist. As many as 25% of females who have chlamydial infections also have gonorrhea. The inflamed cervix that results from this infection may leave a woman more vulnerable to HIV transmission from an infected partner. Gonorrhea is also a major cause of PID, tubal infertility, ectopic pregnancy, and chronic pelvic pain. Fifty percent of women with gonorrhea have no symptoms, but without treat-
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ment 40% may develop PID. In males, urethritis and epididymitis may occur. Diagnosis can be confirmed by culture, smear, or other methods, using a swab to obtain a sample of cervical discharge or penile discharge from the patient’s partner.
Medical Management The Centers for Disease Control and Prevention (CDC) recommends treating chlamydia with doxycycline for 1 week or with a single dose of azithromycin. Because of the high incidence of coinfection with chlamydia and gonorrhea, treatment for gonorrhea should include treatment for chlamydia as well (CDC, 2002). Partners must also be treated. Pregnant women are cautioned not to take tetracycline because of potential adverse effects on the fetus. In these cases, erythromycin may be prescribed. Results are usually good if treatment begins early. Possible complications from delayed treatment are tubal disease, ectopic pregnancy, PID, and infertility. Cultures for chlamydia and other STDs should be obtained from all patients who have been sexually assaulted when they first seek medical attention; patients are treated prophylactically. Cultures should then be repeated in 2 weeks. Annual screening for chlamydia is recommended for all sexually active women 20 to 25 years of age and older women with new sex partners or multiple partners (CDC, 2002).
Nursing Management All sexually active women may be at risk for chlamydia, gonorrhea, and other STDs, including HIV. Nurses can assist patients in assessing their own risk. Recognition of risk is a first step before changes in behavior occur. Patients should be discouraged from assuming that a partner is “safe” without open, honest discussion. Nonjudgmental attitudes, educational counseling, and role playing may all be helpful. Because chlamydia, gonorrhea, and other STDs may have a serious effect on future health and fertility and because many STDs can be prevented by the use of condoms and spermicides and careful choice of partners, the nurse can play a major role in talking with patients about how to make sex as safe as possible. Exploring options with patients, determining their use of safer sex practices and their knowledge deficits, and correcting misinformation may prevent morbidity and mortality. PROMOTING HOME AND COMMUNITY-BASED CARE Teaching Patients Self-Care. Nurses can educate women and help them to develop communication skills and to initiate discussions about sex with their partners. Communicating with partners about sex, risk, postponing intercourse, and using safer sex behaviors, including use of condoms, may be lifesaving. Some young women report having sex with someone but not being comfortable enough to discuss sexual risk issues. The nurse can pose the question, “If you are uncomfortable talking about sex with this person, how do you feel about having a sexual relationship with this person?” Reinforcing the need for annual screening for chlamydia and other STDs is an important part of patient teaching. Instructions also include the need for the patient to abstain from sexual intercourse until all of her sex partners are treated (CDC, 2002). The CDC has revised its guidelines and recommends rescreening of all women with chlamydial infections 3 to 4 months after treatment is completed; this is in an effort to protect young women from infertility.
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PELVIC INFECTION (PELVIC INFLAMMATORY DISEASE) Pelvic inflammatory disease (PID) is an inflammatory condition of the pelvic cavity that may begin with cervicitis and may involve the uterus (endometritis), fallopian tubes (salpingitis), ovaries (oophoritis), pelvic peritoneum, or pelvic vascular system. Infection, which may be acute, subacute, recurrent, or chronic and localized or widespread, is usually caused by bacteria but may be attributed to a virus, fungus, or parasite. Gonorrheal and chlamydial organisms are the most likely causes. Cytomegalovirus (CMV) has also been implicated. This condition can result in the fallopian tubes becoming narrowed and scarred, which increases the risk for ectopic pregnancy (fertilized eggs become trapped in the tube), infertility, recurrent pelvic pain, tubo-ovarian abscess, and recurrent disease. Rupture of a tubo-ovarian abscess has a 5% to 10% mortality rate and usually necessitates a complete hysterectomy. About 1 million women are diagnosed with PID each year in the United States; most are younger than 25 years of age, and one fourth of them have serious sequelae (ie, infertility, ectopic pregnancy, or chronic pelvic pain) (Rein, Kasler, Irwin & Rabiee, 2000). PID is the most common gynecologic cause of hospital admissions in the United States. The true incidence of PID is unknown because most cases are asymptomatic (Ross, 2001).
to the fallopian tubes and into the pelvis (see Fig. 47-1). The infection is usually bilateral. In rare instances, organisms (eg, tuberculosis) gain access to the reproductive organs by way of the bloodstream from the lungs (see Fig. 47-1). One of the most common causes of salpingitis (inflammation of the fallopian tube) is chlamydia, possibly accompanied by gonorrhea. Pelvic infection is most commonly caused by sexual transmission but can also occur with invasive procedures such as endometrial biopsy, surgical abortion, hysteroscopy, or IUD insertion. Bacterial vaginosis, a vaginal infection, may predispose women to pelvic infection. Risk factors include early age at first intercourse, multiple sexual partners, frequent intercourse, intercourse without condoms, sex with a partner with an STD, and a history of STDs or previous pelvic infection.
Clinical Manifestations Symptoms of pelvic infection usually begin with vaginal discharge, dyspareunia, lower abdominal pelvic pain, and tenderness that occurs after menses. Pain may increase while voiding or with defecation. Other symptoms include fever, general malaise, anorexia, nausea, headache, and possibly vomiting. On pelvic examination, intense tenderness may be noted on palpation of the uterus or movement of the cervix (cervical motion tenderness). Symptoms may be acute and severe or low-grade and subtle.
Pathophysiology The exact pathogenesis of PID has not been determined, but it is presumed that organisms usually enter the body through the vagina, pass through the cervical canal, colonize the endocervix, and move upward into the uterus. Under various conditions, the organisms may proceed to one or both fallopian tubes and ovaries and into the pelvis. In bacterial infections that occur after childbirth or abortion, pathogens are disseminated directly through the tissues that support the uterus by way of the lymphatics and blood vessels (Fig. 47-1). In pregnancy, the increased blood supply required by the placenta provides more pathways for infection. These postpartum and postabortion infections tend to be unilateral. Infections can cause perihepatic inflammation when the organism invades the peritoneum. In gonorrheal infections, the gonococci pass through the cervical canal and into the uterus, where the environment, especially during menstruation, allows them to multiply rapidly and spread
Spread of bacterial infection
A
FIGURE 47-1
Complications Pelvic or generalized peritonitis, abscesses, strictures, and fallopian tube obstruction may develop. Obstruction may cause an ectopic pregnancy in the future if a fertilized egg cannot pass a tubal stricture, or scar tissue may occlude the tubes, resulting in sterility. Adhesions are common and often result in chronic pelvic pain; they eventually may require removal of the uterus, fallopian tubes, and ovaries. Other complications include bacteremia with septic shock and thrombophlebitis with possible embolization.
Medical Management Broad-spectrum antibiotic therapy is prescribed. Women with mild infections may be treated as outpatients (Ness, Soper, Holley et al., 2002c), but hospitalization may be necessary. Intensive therapy includes bed rest, intravenous fluids, and intravenous antibiotic
Spread of gonorrhea
B
Spread through blood via circulatory system
C
Pathway by which microorganisms spread in pelvic infections. (A) Bacterial infection spreads up the vagina into the uterus and through the lymphatics. (B) Gonorrhea spreads up the vagina into the uterus and then to the tubes and ovaries. (C) Bacterial infection can reach the reproductive organs through the bloodstream (hematogenous spread).
Chapter 47
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therapy. If the patient has abdominal distention or ileus, nasogastric intubation and suction are initiated. Carefully monitoring vital signs and symptoms assists in evaluating the status of the infection. Treating sexual partners is necessary to prevent reinfection.
Nursing Management Infection takes a toll, both physically and emotionally. The patient may feel well one day and experience vague symptoms and discomfort the next. She may also suffer from constipation and menstrual difficulties. The hospitalized patient is maintained on bed rest and is usually placed in the semi-Fowler’s position to facilitate dependent drainage. Accurate recording of vital signs and the characteristics and amount of vaginal discharge is necessary as a guide to therapy. The nurse administers analgesic agents as prescribed for pain relief. Heat applied safely to the abdomen may also provide some pain relief and comfort. The nurse minimizes the transmission of infection to others by carefully handling perineal pads with gloves, discarding the soiled pad according to hospital guidelines for disposal of biohazardous material, and performing meticulous hand hygiene. PROMOTING HOME AND COMMUNITY-BASED CARE Teaching Patients Self-Care. The patient must be informed of the need for precautions and must be encouraged to take part in procedures to prevent infecting others and protecting herself from reinfection. If a partner is not well known or has had other sexual partners recently, use of condoms may prevent life-threatening infection and its sequelae. If reinfection occurs or if the infection spreads, symptoms may include abdominal pain, nausea and vomiting, fever, malaise, malodorous purulent vaginal discharge, and leukocytosis. Patient teaching consists of explaining how pelvic infections occur, how they can be controlled and avoided, and their signs and symptoms. Guidelines and instructions provided to the patient are summarized in the accompanying Home Care Checklist (Chart 47-3). All patients who have had PID need to be informed of the signs and symptoms of ectopic pregnancy (pain, abnormal bleeding, delayed menses, faintness, dizziness, and shoulder pain) because they are prone to this complication. (See Chap. 46 for a discussion of ectopic pregnancy.)
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HUMAN IMMUNODEFICIENCY VIRUS INFECTION AND ACQUIRED IMMUNODEFICIENCY SYNDROME Any discussion of vulvovaginal infections must include the topic of HIV and acquired immunodeficiency syndrome (AIDS), described in Chapter 52. The incidence of HIV infection and AIDS is increasing in women. Females represent the fastest-growing segment of the AIDS epidemic. Most are in the reproductive age group, and more than 70% are African American or Hispanic. More than half are intravenous (or injecting) drug users, whereas the other half have been exposed through sexual contact with HIV-infected partners. Women who exchange sex for drugs are at high risk, as are women who engage in anal intercourse. Heterosexual transmission is the leading cause of new HIV infection in women. Women are nine times more likely to get HIV from men than men are from women. Factors that may account for this difference include a higher quantity of HIV in semen as compared with vaginal secretions, a larger inoculum on ejaculation, retention of HIV-infected semen in the vagina, and traumatic microscopic mucosal injury during intercourse. The presence of genital ulcers or a friable cervix increases risk. Intercourse during menses may also increase risk. Additionally, any break in skin integrity increases the possibility of infection (eg, a herpetic lesion or syphilitic chancre could provide a portal of entry). Nurses need to inform women about the dangers of unprotected sex (Hader, Smith, Moore & Holmberg, 2001; Healthy People 2010, 2000). Syphilis appears to accelerate in HIV-positive patients and proceeds directly from primary to tertiary disease in some patients. Chlamydia is associated with a high risk for HIV (which may be related to inflammatory changes of the cervix, providing entry sites). HIV-positive women have a higher rate of HPV, and this risk increases as their CD4 cell count decreases. Infections with HPV and HIV together increase the risk of malignant transformation and cervical cancer. This risk also increases as the CD4 cell count decreases. Thus, women with HIV infection should have frequent Pap smears. HIV-positive women also have larger and more painful herpes lesions with more recurrences, probably related to immunosuppression from their disease. Treatment with acyclovir or other antiviral agents is appropriate for such patients. Pneumonitis, esophagitis, and disseminated skin involvement are common in this population. Candidiasis also occurs frequently in this population; oral candidiasis may signal rapidly advancing disease. Many HIV-infected women have gynecologic disorders,
Chart 47-3 Home Care Checklist • The Patient With Pelvic Inflammatory Disease At the completion of the home care instruction, the patient or caregiver will be able to: Patient • State that any pelvic pain and/or abnormal discharge, particularly after sexual exposure, childbirth, or pelvic surgery, should be evaluated as soon as possible. ✓ ✓ • State that antibiotics may be prescribed after insertion of intrauterine devices (IUDs). ✓ • Describe proper perineal care procedures (wiping from front to back after defecation or urination). ✓ • State that douching reduces the natural flora that combat infecting organisms and may introduce bacteria upward. ✓ • Identify the importance of consulting a health care provider if unusual vaginal discharge or odor is noted. • Discuss the importance of following health practices (ie, proper nutrition, exercise, and weight control), and safer sex practices (ie, using condoms, avoiding multiple sexual partners). ✓ • Explain the importance of consistent use of condoms before intercourse or any penile–vaginal contact if there is any chance of transmitting infection. ✓ ✓ • State that a gynecologic examination should be performed at least once a year.
Caregiver
✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓
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including candidiasis, PID, anogenital warts, and cervical dysplasia (Healthy People 2010, 2000). Women with HIV and women with partners who have HIV must be counseled about safer sex. Consistent use of condoms with an HIV-infected partner can keep seroconversion rates to about 1%, but inconsistent use results in an annual 7.2% seroconversion rate. Because there is a 25% to 30% chance of perinatal transmission, decisions to conceive or to use contraception must be based on teaching and care. (The use of antiretroviral agents by pregnant women has been shown to decrease perinatal transmission of HIV infection significantly. Therefore, the use of these agents during pregnancy must also be discussed.) For those who choose to avoid conception, condoms or condoms with oral contraceptives are possible choices. Women who are at risk for HIV should be offered testing after informed consent by a trained nurse or counselor. Because patients may be reluctant to discuss risk-taking behavior, routine screening should be offered to all women. Early detection permits early treatment to delay progression of the disease. The nurse plays a crucial role in educating patients about HIV and prevention of HIV infection and AIDS.
Structural Disorders FISTULAS OF THE VAGINA A fistula is an abnormal, tortuous opening between two internal hollow organs or between an internal hollow organ and the exterior of the body. The name of the fistula indicates the two areas that are connected abnormally: a vesicovaginal fistula is an opening between the bladder and the vagina, and a rectovaginal fistula is an opening between the rectum and the vagina (Fig. 47-2). Fistulas may be congenital in origin. In adults, however, breakdown usually occurs because of tissue damage resulting from injury sustained during surgery, vaginal delivery, radiation therapy, or disease processes such as carcinoma.
Clinical Manifestations Symptoms depend on the specific defect. For example, in the patient with a vesicovaginal fistula, urine escapes continuously into the vagina. With a rectovaginal fistula, there is fecal incontinence,
Uterus Bladder Ureterovaginal Vesicovaginal Urethrovaginal Vagina Rectovaginal Vaginoperineal Rectum
FIGURE 47-2 Common sites for vaginal fistulas: Vesicovaginal—bladder and vagina. Urethrovaginal—urethra and vagina. Vaginoperineal—vagina and perineal area. Ureterovaginal—ureter and vagina. Rectovaginal—rectum and vagina.
and flatus is discharged through the vagina. The combination of fecal discharge with leukorrhea results in malodor that is difficult to control.
Assessment and Diagnostic Findings A history of the symptoms experienced by the patient is important to identify the structural alterations and to assess the impact of the symptoms on the patient’s quality of life. In addition, the use of methylene blue dye helps delineate the course of the fistula. In vesicovaginal fistula, the dye is instilled into the bladder and appears in the vagina. After a negative methylene blue test result, indigo carmine is injected intravenously; the appearance of the dye in the vagina indicates a ureterovaginal fistula. Cystoscopy or intravenous pyelography may then be used to determine the exact location.
Medical Management The goal is to eliminate the fistula and to treat infection and excoriation. A fistula may heal without surgical intervention, but surgery is often required. If the primary care provider determines that a fistula will heal without surgical intervention, care is planned to relieve discomfort, prevent infection, and improve the patient’s self-concept and self-care abilities. Measures to effect healing include proper nutrition, cleansing douches and enemas, rest, and administration of prescribed intestinal antibiotic agents. A rectovaginal fistula heals faster when the patient eats a low-residue diet and when the affected tissue drains properly. Warm perineal irrigations and controlled heat-lamp treatments promote healing. Sometimes a fistula does not heal on its own and cannot be surgically repaired. In this situation care must be planned and implemented on an individual basis. Cleanliness, frequent sitz baths, and deodorizing douches are required, as are perineal pads and protective undergarments. Meticulous skin care is necessary to prevent excoriation. Applying bland creams or lightly dusting with cornstarch may be soothing. Additionally, attending to the patient’s social and psychological needs is an essential aspect of care. If the patient will have a fistula repaired surgically, preoperative treatment of any existing vaginitis is important to ensure success. Usually, the vaginal approach is used to repair vesicovaginal and urethrovaginal fistulas; the abdominal approach is used to repair fistulas that are large or complex. Fistulas that are difficult to repair or that are very large may require surgical repair with a urinary or fecal diversion. Because fistulas usually are related to obstetric, surgical, or radiation trauma, occurrence in a patient without previous vaginal delivery or a history of surgery must be evaluated carefully. Crohn’s disease or lymphogranuloma venereum may be the cause. Despite the best surgical intervention, fistulas may recur. After surgery, medical follow-up continues for at least 2 years to monitor for a possible recurrence.
PELVIC ORGAN PROLAPSE: CYSTOCELE, RECTOCELE, ENTEROCELE Time and gravity can put strain on the ligaments and structures that make up the female pelvis. Childbirth can result in tears of the levator sling musculature, resulting in structural weakness. Hormone deficiency also may play a role. Cystocele is a downward displacement of the bladder toward the vaginal orifice (Fig. 47-3) resulting from damage to the an-
Chapter 47
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Management of Patients With Female Reproductive Disorders
B
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C
FIGURE 47-3 Diagrammatic representation of the three most common types of pelvic floor relaxation: (A) cystocele, (B) rectocele, and (C) enterocele. Arrows depict sites of maximum protrusion. terior vaginal support structures. It usually results from injury and strain during childbirth. The condition usually appears some years later when genital atrophy associated with aging occurs, but younger, multiparous, premenopausal women may also be affected. Rectocele and perineal lacerations may affect the muscles and tissues of the pelvic floor and may occur during childbirth. Because of muscle tears below the vagina, the rectum may pouch upward, thereby pushing the posterior wall of the vagina forward. This structural abnormality is called a rectocele. Sometimes the lacerations may completely sever the fibers of the anal sphincter (complete tear). An enterocele is a protrusion of the intestinal wall into the vagina. Prolapse (if complete prolapse occurs, it may also be referred to as procidentia) results from a weakening of the support structures of the uterus itself; the cervix drops and may protrude from the vagina.
Clinical Manifestations Because a cystocele causes the anterior vaginal wall to bulge downward, the patient may report a sense of pelvic pressure, fatigue, and urinary problems such as incontinence, frequency, and urgency. Back pain and pelvic pain may occur as well. The symptoms of rectocele resemble those of cystocele, with one exception: instead of urinary symptoms, the patient may experience rectal pressure. Constipation, uncontrollable gas, and fecal incontinence may occur in patients with complete tears. Prolapse can result in feelings of pressure and ulcerations and bleeding. Dyspareunia may occur with these disorders.
Medical Management Kegel exercises, which involve contracting or tightening the vaginal muscles, are prescribed to help strengthen these weakened muscles. The exercises are more effective in the early stages of a cystocele. Kegel exercises are easy to do and are recommended for all women, including those with strong pelvic floor muscles (Chart 47-4). Pessaries can be used to avoid surgery. This device is inserted into the vagina and positioned to keep an organ, such as the bladder, uterus, or intestine, properly aligned when a cystocele, rectocele, or prolapse has occurred. Pessaries are usually ringshaped or doughnut-shaped and are made of various materials, such as rubber or plastic (Fig. 47-4). Rubber pessaries must be avoided in women with latex allergy. The size and type of pessary
are selected and fitted by a gynecologic health care provider. The patient should have the pessary removed, examined, and cleaned by her health care provider at prescribed intervals. At this checkup, vaginal walls are examined for pressure points or signs of irritation. Normally, the patient experiences no pain, discomfort, or discharge with a pessary, but if chronic irritation occurs, alternative measures may be needed. SURGICAL MANAGEMENT In many cases, surgery helps to correct structural abnormalities. The procedure to repair the anterior vaginal wall is called anterior colporrhaphy, repair of a rectocele is called a posterior colporrhaphy, and repair of perineal lacerations is called a perineorrhaphy. These repairs are frequently performed laparoscopically, resulting in short hospital stays and good outcomes. A laparoscope is inserted through a small abdominal incision, the pelvis is visualized, and surgical repairs are performed.
UTERINE PROLAPSE Usually, the uterus and the cervix lie at right angles to the long axis of the vagina and with the body of the uterus inclined slightly forward. The uterus is normally freely movable upon examination. Individual variations may result in an anterior, middle, or posterior uterine position. A backward positioning of the uterus, known as retroversion and retroflexion, is not uncommon (Fig. 47-5).
Chart 47-4
• PATIENT EDUCATION Performing Kegel (Pelvic Muscle) Exercises Purposes: To strengthen and maintain the tone of the pubococcygeal muscle, which supports the pelvic organs; reduce or prevent stress incontinence and uterine prolapse; enhance sensation during sexual intercourse; and hasten postpartum healing 1. Become aware of pelvic muscle function by “drawing in” the perivaginal muscles and anal sphincter as if to control urine or defecation, but not contracting the abdominal, buttock, or inner thigh muscles. 2. Sustain contraction of the muscles for up to 10 seconds, followed by at least 10 seconds of relaxation. 3. Perform these exercises 30–80 times a day. Training and exercise should be individualized for each patient.
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B
A
FIGURE 47-4
Examples of pessaries. (A) Various shapes and sizes of pessaries available. (B) Insertion of one type of
pessary.
A
D
B
C
E
FIGURE 47-5 Positions of the uterus. (A) The most common position of the uterus detected on palpation. (B) In retroversion the uterus turns posteriorly as a whole unit. (C) In retroflexion the fundus bends posteriorly. (D) In anteversion the uterus tilts forward as a whole unit. (E) In anteflexion the uterus bends anteriorly.
Chapter 47
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If the structures that support the uterus weaken (typically from childbirth), the uterus may work its way down the vaginal canal (prolapse) and even appear outside the vaginal orifice (procidentia) (Fig. 47-6). As the uterus descends, it may pull the vaginal walls and even the bladder and rectum with it. Symptoms include pressure and urinary problems (incontinence or retention) from displacement of the bladder. The problems are aggravated when the woman coughs, lifts a heavy object, or stands for a long time. Normal activities, even walking up stairs, may aggravate the problem.
Medical Management Pessaries and surgery are two options for treatment. If surgery is the method of treatment used, the uterus is sutured back into place and repaired to strengthen and tighten the muscle bands. In postmenopausal women, the uterus may be removed (hysterectomy). For elderly women or those who are too ill to withstand the strain of surgery, pessaries may be the treatment of choice.
Nursing Management IMPLEMENTING PREVENTIVE MEASURES Some problems related to “relaxed” pelvic muscles (cystocele, rectocele, and uterine prolapse) may be prevented. During pregnancy, early visits to the health care provider permit early detection of problems. During the postpartum period, the woman can be taught to perform Kegel exercises to strengthen the muscles that support the uterus. Delays in obtaining evaluation and treatment may result in complications such as infection, cervical ulceration, cystitis, and hemorrhoids. The nurse encourages the patient to obtain prompt treatment for these structural disorders. IMPLEMENTING PREOPERATIVE NURSING CARE Before surgery, the patient needs to know the extent of the proposed surgery, the expectations for the postoperative period, and the effect of surgery on future sexual function. In addition, the patient having a rectocele repair needs to know that before surgery, a laxative and a cleansing enema may be prescribed. She may be asked to administer these at home the day before surgery. A perineal shave may be prescribed as well. The patient is usually placed
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in a lithotomy position for surgery, with special attention given to moving both legs in and out of the stirrups simultaneously to prevent muscle strain and excess pressure on the legs and thighs. Other preoperative interventions are similar to those described in Chapter 18. INITIATING POSTOPERATIVE NURSING CARE Immediate postoperative goals include preventing infection and pressure on any existing suture line. This may require perineal care and may preclude using dressings. The patient is encouraged to void within a few hours after surgery for cystocele and complete tear. If the patient does not void within this period and reports discomfort or pain in the bladder region after 6 hours, she will need to be catheterized. Some physicians prefer to leave an indwelling catheter in place for 2 to 4 days, so some women may return home with a catheter in place. Various other bladder care methods are described in Chapter 44. After each voiding or bowel movement, the perineum is cleansed with warm, sterile saline solution and dried with sterile absorbent material if a perineal incision has been made. After an external perineal repair, several methods are used in caring for the sutures. In one method, the sutures are left alone until healing occurs (in 5 to 10 days). Thereafter, daily vaginal douches with sterile saline solution may be administered during recovery. In another method—the wet method—small, sterile saline douches are administered twice daily, beginning on the day after surgery and continuing throughout recovery. A heat lamp or hair dryer may be used to help dry the area and promote healing. Commercially available sprays containing combined antiseptic and anesthetic solutions are soothing and effective, and an ice pack applied locally may relieve discomfort. However, the weight of the ice bag must rest on the bed and not on the patient. Routine postoperative care is similar to that given after abdominal surgery. The patient is positioned in bed with the head and knees elevated slightly. The patient may go home the day of or the day after surgery; the duration of the hospital stay depends on the surgical approach used. After surgery for a complete perineal laceration (through the rectal sphincter), special care and attention are required. The bladder is drained through the catheter to prevent strain on the sutures. Throughout recovery, stool-softening agents are administered nightly after the patient begins a soft diet. PROMOTING HOME AND COMMUNITY-BASED CARE Teaching Patients Self-Care. Predischarge instructions include information pertaining to the gynecologist’s postoperative instructions related to douching, using mild laxatives, performing exercise as recommended, and avoiding lifting heavy objects or standing for prolonged periods. The patient is reminded to return to the gynecologist for a follow-up visit and to consult with the physician about when it is safe to resume sexual intercourse. The patient is instructed to report any pelvic pain, unusual discharge, inability to carry out personal hygiene, and vaginal bleeding. She is advised to continue with perineal exercises, which are recommended to improve muscle strength and tone.
Benign Disorders FIGURE 47-6
Complete prolapse of the uterus through the introitus.
Vulvitis, an inflammation of the vulva, may occur with other disorders, such as diabetes, dermatologic problems, or poor hygiene, or it may be secondary to irritation from a vaginal discharge related to a specific vaginitis.
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Vulvodynia is a chronic syndrome of vulvar discomfort. Symptoms may include burning, stinging, irritation or excoriation. It has been described as primary, with onset at first tampon insertion or sexual experience, or secondary, beginning months or years after first tampon insertion or sexual experience. It may be classified as organic if it has a known cause (infection, trauma, or irritants) or idiopathic if no cause is known. It seems to be similar to a peripheral neuralgia and may respond to treatment with tricyclic antidepressants. Cyclic vulvitis is a subset of vulvodynia and is characterized by episodes of vulvar discomfort. Typical complaints are recurrent itching and burning, often worsening with menses and after sexual intercourse. Erythema and swelling may occur. It is often related to candidal infection, and fungal cultures are often positive. Vulvar vestibulitis is a chronic persistent syndrome of severe pain on touch to the vestibular area or attempted vaginal entry, and physical findings of vestibular erythema. Treatment methods vary. Research is ongoing to identify treatment for vulvar vestibulitis, but topical treatments (ie, estrogens, corticosteroids, trichloroacetic acid), surgery, and interferon have been used. Biofeedback has also been used.
VULVAR CYSTS Bartholin’s cyst results from the obstruction of a duct in one of the paired vestibular glands located in the posterior third of the vulva, near the vestibule. This cyst is the most common of vulvar tumors. A simple cyst may be asymptomatic, but an infected cyst or abscess may cause discomfort. Infection may be due to a gonococcal organism, Escherichia coli, or S. aureus and can cause an abscess with or without involving the inguinal lymph nodes. Skene’s duct cysts may result in pressure, dyspareunia, altered urinary stream, and pain, especially if infection is present. Vestibular cysts, located inferior to the hymen, may also occur.
Medical Management The usual treatment for a Bartholin’s cyst is incision and drainage followed by antibiotic therapy. If a cyst is asymptomatic, treatment is unnecessary. Moist heat or sitz baths may promote drainage and resolution. If surgery is necessary, a Word Bartholin gland catheter is usually used. This catheter, a short latex stem with an inflatable bulb at the distal end, creates a tract that preserves the gland and allows for drainage. A nonopioid analgesic agent may be administered before this outpatient procedure. A local anesthetic agent is injected, and the cyst is incised or lanced and irrigated with normal saline; the catheter is inserted and inflated with 2 to 3 mL of water. The catheter stem is then tucked into the vagina to allow freedom of movement. The catheter is left in place for 4 to 6 weeks until the tract re-epithelializes. The patient is informed that discharge should be expected, as the catheter allows drainage of the cyst. She is instructed to contact her primary health care provider if pain occurs because the bulb may be too large for the cavity and fluid may need to be removed. Routine hygiene is encouraged. Skene’s duct cysts can be excised or drained with a Word catheter. Vestibular cysts are excised if symptomatic.
VULVAR DYSTROPHY Vulvar dystrophy is a condition found in older women that causes dry, thickened skin on the vulva or slightly raised, whitish papules, fissures, or macules. Symptoms usually consist of varying degrees of itching, but some patients have no symptoms. A few pa-
tients with vulvar cancer have associated dystrophy (vulvar cancer is discussed later in this chapter). Biopsy with careful follow-up is the standard intervention. Benign dystrophies include lichen planus, simplex chronicus, lichen sclerosus, squamous cell hyperplasia, vulvar vestibulitis, and other dermatoses (Chart 47-5).
Medical Management Topical corticosteroids (ie, hydrocortisone suppositories) are the usual treatment for lichen planus. Petrolatum jelly may relieve pruritus. Use is decreased as symptoms abate. Topical corticosteroids are effective in treating squamous cell hyperplasia. Treatment is often complete in 2 to 3 weeks; this condition is not likely to recur after treatment is complete. If malignant cells are detected on biopsy, local excision, laser therapy, local chemotherapy, and immunologic treatment are used. Vulvectomy is avoided, if possible, to spare the patient from the stress of disfigurement and possible sexual dysfunction.
Nursing Management Key nursing responsibilities for patients with vulvar dystrophies focus on teaching. Important topics include hygiene and selfmonitoring for signs and symptoms of complications. PROMOTING HOME AND COMMUNITY-BASED CARE Teaching Patients Self-Care. Instructions for patients with benign vulvar dystrophies include the importance of maintaining good personal hygiene and keeping the vulva dry. Lanolin or hydrogenated vegetable oil is recommended for relief of dryness. Sitz baths may help but should not be overused because dryness
Chart 47-5
Types of Benign Vulvar Disorders
Lichen Planus and Simplex Chronicus • Chronic vulvar and vaginal disorders that are diagnosed by biopsy • May appear as mild inflammation or as severe erosion • Result in redness, lesions, pain, and dyspareunia Lichen Sclerosus • A benign epithelial disorder that is most common in prepubertal and postmenopausal females • A familial tendency toward this condition may exist. • Epithelial thinning, edema, and fibrosis occur, and the vulva appears white and paper thin. • Bleeding and pruritus may occur, and intercourse may be difficult. • Diagnosis is confirmed by biopsy. Squamous Cell Hyperplasia • A benign epithelial disorder that may look like lichen sclerosus but is not inflamed • Causes itching and plaquelike excoriated skin • Must be differentiated from vulvar intraepithelial neoplasia or carcinoma in situ by biopsy Vulvar Vestibulitis • An inflammatory process associated with vulvodynia and possibly interstitial cystitis • Causes pain during and after intercourse; discomfort may also preclude intercourse • Onset of symptoms may be related to vaginal infection, laser treatment, history of sexual abuse, or excessive washing with irritant soaps. • Examination reveals redness, inflammation, and tenderness.
Chapter 47
Management of Patients With Female Reproductive Disorders
may result or increase. The patient is instructed to notify her primary health care provider about any change or ulceration because biopsy may be necessary to rule out squamous cell carcinoma. By encouraging all patients to perform genital self-examinations regularly and have any itching, lesions, or unusual symptoms assessed by a health care provider, nurses can help prevent complications and progression of vulvar lesions.
OVARIAN CYSTS The ovary is a common site for cysts, which may be simple enlargements of normal ovarian constituents, the graafian follicle, or the corpus luteum, or they may arise from abnormal growth of the ovarian epithelium. Dermoid cysts are tumors that are thought to arise from parts of the ovum that normally disappear with ripening (maturation). Their origin is undefined, and they consist of undifferentiated embryonal cells. They grow slowly and are found during surgery to contain a thick, yellow, sebaceous material arising from the skin lining. Hair, teeth, bone, and many other tissues are found in a rudimentary state within these cysts. Dermoid cysts are only one type of lesion that may develop. Many other types can occur, and treatment usually depends on the type. The patient may or may not report acute or chronic abdominal pain. Symptoms of a ruptured cyst mimic various acute abdominal emergencies, such as appendicitis or ectopic pregnancy. Larger cysts may produce abdominal swelling and exert pressure on adjacent abdominal organs. Polycystic ovary syndrome, a complex endocrine condition involving a disorder in the hypothalamic-pituitary and ovarian network or axis resulting in anovulation, occurs in women of childbearing age. Symptoms are related to androgen excess. Irregular periods resulting from lack of regular ovulation, obesity, and hirsutism may be presenting complaints. Cysts form in the ovaries because the hormonal milieu cannot cause ovulation on a regular basis. Onset may occur at menarche or later. When pregnancy is desired, medications to stimulate ovulation are often effective. Women with polycystic ovary syndrome may develop insulin resistance and may be at higher risk for cardiac disorders in later life.
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BENIGN TUMORS OF THE UTERUS: FIBROIDS (LEIOMYOMAS, MYOMAS) Myomatous or fibroid tumors of the uterus are estimated to occur in 25% of women over age 30. Some women are genetically predisposed. They are a common reason for hysterectomy as they often result in menorrhagia that can be difficult to control. They arise from the muscle tissue of the uterus and can be found in the lining (intracavitary), muscle wall (intramural), and outside surface (serosal) of the uterus. They develop slowly in women between the ages of 25 and 40 and may become large. Fibroids may cause no symptoms, or they may produce abnormal vaginal bleeding. Other symptoms are due to pressure on the surrounding organs and include pain, backache, constipation, and urinary problems. Menorrhagia (excessive bleeding) and metrorrhagia (irregular bleeding) may occur because fibroids may distort the uterine lining (Fig. 47-7).
Medical Management The treatment of uterine fibroids depends to a large extent on their size, symptoms, and location. The patient with minor symptoms is closely monitored. If she plans to have children, treatment is as conservative as possible. As a rule, large tumors that produce pressure symptoms should be removed (myomectomy). The uterus may be removed (hysterectomy) if symptoms are bothersome and childbearing is completed (see later discussion of nursing care for a patient having a hysterectomy). Several other alternatives to hysterectomy have been developed for the treatment of excessive bleeding due to fibroids. These include:
• Hysteroscopic resection of myomas: a laser is used through
a hysteroscope passed through the cervix; no incision or overnight stay is needed
Intramural myomas
Medical Management The treatment of large ovarian cysts is usually surgical removal. For cysts that are small and appear to be fluid-filled or physiologic in a young, healthy patient, however, oral contraceptives may be used to suppress ovarian activity and resolve the cyst. Oral contraceptives are also usually prescribed to treat polycystic ovary syndrome. About 98% of cysts that occur in women aged 29 years and younger are benign. In women older than 50 years of age, only half of these cysts are benign. The postoperative nursing care after surgery to remove an ovarian cyst is similar to that after abdominal surgery, with one exception. The marked decrease in intra-abdominal pressure resulting from removal of a large cyst usually leads to considerable abdominal distention. This complication may be prevented to some extent by applying a snug-fitting abdominal binder. Some surgeons discuss the option of a hysterectomy when a woman is undergoing a bilateral ovary removal because of a suspicious mass because it may increase life expectancy, avoid a later second surgery, and save on health care costs. It is preventive in that future cancer is avoided, as is benign disease that might require hysterectomy. Patient preference is a priority in determining its appropriateness.
Pedunculated intracavitary myoma Pedunculated serosal myoma Protruding intracavitary myoma
FIGURE 47-7 Myomas (fibroids) that impinge on the uterine cavity are called intracavitary myomas.
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• Laparoscopic myomectomy: removal of a fibroid through a • • •
laparoscope inserted through a small abdominal incision Laparoscopic myolysis: a laser or electrical needles are used to cauterize and shrink the fibroid Laparoscopic cryomyolysis: electric current is used to coagulate the fibroid Uterine artery embolization: polyvinyl alcohol particles are injected into the blood vessels that supply the fibroid, shrinking it; this procedure may result in serious complications such as pain, infection, and bleeding
Fibroids usually shrink and disappear during menopause, when estrogen is no longer produced. Medications (eg, leuprolide [Lupron]) or other GnRH analogs that induce medical menopause may be prescribed to shrink the tumors. This treatment consists of monthly injections, which may cause hot flashes and vaginal dryness. This treatment is usually short term (ie, before surgery) to shrink the fibroids, allowing easier surgery, and to alleviate anemia, which may coexist due to heavy menstrual flow. Antifibrotic agents are under investigation for long-term treatment of fibroids. Mifepristone (RU 486), a progesterone antagonist, has also been prescribed.
ENDOMETRIOSIS In endometriosis, a benign lesion or lesions with cells similar to those lining the uterus grow aberrantly in the pelvic cavity outside the uterus. Often, extensive endometriosis causes few symptoms, whereas an isolated lesion may produce severe symptoms. Between 7% and 10% of women in the United States are affected by this disorder (Olive & Pritts, 2001). It is a major cause of chronic pelvic pain and infertility. In order of frequency, pelvic endometriosis involves the ovary, uterosacral ligaments, cul-de-sac, rectovaginal septum, uterovesical peritoneum, cervix, outer surface of the uterus, umbilicus, laparotomy scar tissue, hernial sacs, and appendix. Endometriosis has been diagnosed more frequently as a result of the increased use of laparoscopy. Before laparoscopy, major surgery was necessary before a diagnosis could be made. There is a high incidence among patients who bear children late and among those who have fewer children. In countries where tradition favors early marriage and early childbearing, endometriosis is rare. There also appears to be a familial predisposition to endometriosis; it is more common in women whose close female relatives are affected. Other factors that may suggest increased risk include a shorter menstrual cycle (less than every 27 days), flow longer than 7 days, outflow obstruction, and younger age at menarche. Characteristically, endometriosis is found in young, nulliparous women between the ages of 25 and 35 years. It is also found in teens, particularly those with dysmenorrhea that does not respond to NSAIDs or oral contraceptives.
Pathophysiology Misplaced endometrial tissue responds to and depends on ovarian hormonal stimulation. During menstruation, this ectopic tissue bleeds, mostly into areas having no outlet, which causes pain and adhesions. The lesions are typically small and puckered, with a blue/brown/gray powder-burn appearance and brown or blueblack appearance, indicating concealed bleeding. They may also have an atypical appearance as red, white, petechial, and reddishbrown implants. Endometrial tissue contained within an ovarian cyst has no outlet for the bleeding; this formation is referred to as a pseudo-
cyst or chocolate cyst. Adhesions, cysts, and scar tissue may result, causing pain and infertility. Currently the best-accepted theory regarding the origin of endometrial lesions is the transplantation theory, which suggests that a backflow of menses (retrograde menstruation) transports endometrial tissue to ectopic sites through the fallopian tubes. Transplantation of tissue can also occur during surgery if endometrial tissue is transferred inadvertently by way of surgical instruments. Retrograde menstruation has been found to occur in many women, not just those with endometriosis. Why some women develop this condition and others do not is unknown. Endometrial tissue can also be spread by lymphatic or venous channels.
Clinical Manifestations Symptoms vary but include dysmenorrhea, dyspareunia, and pelvic discomfort or pain. Dyschezia (pain with bowel movements) and radiation of pain to the back or leg may occur. Depression, loss of work due to pain, and relationship difficulties may result. Infertility may occur because of fibrosis and adhesions or because of a variety of substances (prostaglandins, cytokines, other factors) produced by the implants (Olive & Pritts, 2001).
Assessment and Diagnostic Findings A health history, including an account of the menstrual pattern, is necessary to elicit specific symptoms. On bimanual pelvic examination, fixed tender nodules are sometimes palpated and uterine mobility may be limited, indicating adhesions. Laparoscopic examination confirms the diagnosis and helps to stage the disease. In stage 1, the patient has superficial or minimal lesions; stage 2, mild involvement; stage 3, moderate involvement; and stage 4, deep involvement and dense adhesions, with obliteration of the cul-de-sac.
Medical Management Treatment depends on the symptoms, the patient’s desire for pregnancy, and the extent of the disease. If the woman does not have symptoms, routine examination may be all that is required. Other therapy for varying degrees of symptoms may be NSAIDs, oral contraceptives, GnRH agonists, or surgery. Pregnancy often alleviates symptoms because neither ovulation nor menstruation occurs. PHARMACOLOGIC THERAPY Palliative measures include use of medications, such as analgesic agents and prostaglandin inhibitors, for pain. Hormonal therapy is effective in suppressing endometriosis and relieving dysmenorrhea (menstrual pain). Oral contraceptives are used frequently. Side effects that may occur with oral contraceptives include fluid retention, weight gain, or nausea. These can usually be managed by changing brands or formulations. Depo-Provera or Lunelle, injectable contraceptive agents, may also be used. Several types of hormonal therapy are also available in addition to the oral contraceptives. A synthetic androgen, danazol (Danocrine), causes atrophy of the endometrium and subsequent amenorrhea. The medication inhibits the release of gonadotropin with minimal overt sex hormone stimulation. The drawbacks of this medication are that it is expensive and may cause troublesome side effects such as fatigue, depression, weight gain, oily skin, decreased breast size, mild acne, hot flashes, and vaginal at-
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rophy. GnRH agonists decrease estrogen production and cause subsequent amenorrhea. Side effects are related to low estrogen levels (eg, hot flashes and vaginal dryness). Loss of bone density is often offset by concurrent use of estrogen. Leuprolide, another medication, is injected monthly to suppress hormones, induce an artificial menopause, and thereby avoid menstrual effects and relieve endometriosis. Some clinicians prescribe a combination of therapies. Most women continue treatment despite side effects, and symptoms diminish for 80% to 90% of women with mild to moderate endometriosis. Assisted reproductive techniques may be warranted and effective in women with infertility secondary to endometriosis (Olive & Pritts, 2002). Hormonal medications are not used, however, in patients with a history of abnormal vaginal bleeding or liver, heart, or kidney disease. Bone density is followed carefully because of the risk of bone loss; hormone therapy is usually short-term. SURGICAL MANAGEMENT If conservative measures are not helpful, surgery may be necessary to relieve pain and enhance the possibility of pregnancy. Surgery may be combined with use of medical therapy. The procedure selected depends on the patient. Laparoscopy may be used to fulgurate (cut with high-frequency current) endometrial implants and to release adhesions. Laser surgery is another option made possible by laparoscopy. Laser therapy vaporizes or coagulates the endometrial implants, thereby destroying this tissue. Other surgical options include endocoagulation and electrocoagulation, laparotomy, abdominal hysterectomy, oophorectomy, bilateral salpingo-oophorectomy, and appendectomy. For women older than 35 or those willing to sacrifice reproductive capability, total hysterectomy is an option. Endometriosis recurs in many women.
Nursing Management The health history and physical examination focus on specific symptoms (eg, pain) and when and how long they have been bothersome, the effect of prescribed medications, and the woman’s reproductive plans. This information helps in determining the treatment plan. Explaining the various diagnostic procedures may help to alleviate the patient’s anxiety. Patient goals include relief of pain, dysmenorrhea, dyspareunia, and avoidance of infertility. As the treatment progresses, the woman with endometriosis and her partner may find that pregnancy is not easily possible, and the psychosocial impact of this realization must be recognized and addressed. Alternatives, such as in vitro fertilization or adoption, may be discussed at an appropriate time and referrals offered. The nurse’s role in patient education is to dispel myths and encourage the patient to seek care if dysmenorrhea or dyspareunia occurs. The Endometriosis Association (listed at the end of this chapter) is a helpful resource for patients seeking further information and support for this condition, which can cause disabling pain and severe emotional distress.
ADENOMYOSIS In adenomyosis, the tissue that lines the endometrium invades the uterine wall. The incidence is highest in women ages 40 to 50. Symptoms include hypermenorrhea (excessive and prolonged bleeding), acquired dysmenorrhea, polymenorrhea (abnormally frequent bleeding), and premenstrual staining. Physical examination findings on palpation include an enlarged, firm, and tender uterus. Treatment depends on the severity of bleeding and pain. Hysterectomy may offer greater relief than more conservative therapies.
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Malignant Conditions Malignant tumors of the female reproductive system (excluding breast cancer) occur in 274,000 women and are estimated to kill more than 27,000 women in the United States each year. Estimated incidence and estimated mortality for the United States in 2000 are (American Cancer Society, 2002):
• Cervical cancer (estimates do not include in situ cancers): • • • •
13,000 new cases, 4,100 deaths Uterine cancer: 39,300 new cases, 6,600 deaths Ovarian cancer: 23,300 new cases, 13,900 deaths Vaginal cancer: 2,000 new cases, 800 deaths Vulvar cancer: 3,800 new cases, 800 deaths
Although some cancers are difficult to detect or prevent, yearly pelvic examination with a Pap smear is a painless and relatively inexpensive method of early detection. Health care providers can encourage women to follow this health practice by providing nonstressful examinations that are educational and supportive and offering an opportunity for the patient to ask questions and clarify misinformation. If more women understood that the pelvic examination and Pap smear do not have to be uncomfortable or embarrassing, early detection rates would undoubtedly improve, and lives would be saved.
CANCER OF THE CERVIX Carcinoma of the cervix is predominantly squamous cell cancer (10% are adenocarcinomas). During the past 20 years, the incidence of invasive cervical cancer has decreased from 14.2 cases per 100,000 women to 7.8 cases per 100,000 women. It is less common than it once was because of early detection of cell changes by Pap smear. However, it is still the third most common female reproductive cancer and affects about 13,000 women in the United States every year (American Cancer Society, 2002). Cervical cancer occurs most commonly in women ages 30 to 45, but it can occur as early as age 18. Risk factors include multiple sex partners, early age at first coitus, short interval between menarche and first coitus, sexual contact with men whose partners have had cervical cancer, exposure to the HPV virus, and smoking (Chart 47-6).
Clinical Manifestations There are several different types of cervical cancer. Most cancers originate in squamous cells, while the remainder are adenocarcinomas or mixed adenosquamous carcinomas. Adenocarcinomas begin in mucus-producing glands and are often due to HPV infection. Most cervical cancers, if not detected and treated, spread to regional pelvic lymph nodes, and local recurrence is not uncommon. Early cervical cancer rarely produces symptoms. If symptoms are present, they may go unnoticed as a thin watery vaginal discharge often noticed after intercourse or douching. When symptoms such as discharge, irregular bleeding, or bleeding after sexual intercourse occur, the disease may be advanced. Advanced disease should not occur if all women have access to gynecologic care and avail themselves of it. The nurse’s role in access and utilization is crucial and may prevent the delay of detection of cervical cancer until the advanced stage. In advanced cervical cancer, the vaginal discharge gradually increases and becomes watery and, finally, dark and foul-smelling from necrosis and infection of the tumor. The bleeding, which occurs at irregular intervals between periods (metrorrhagia) or after menopause, may be slight (just enough to spot the undergarments)
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Chart 47-6
Risk Factors for Cervical Cancer Risk Factors Sexual activity: Multiple sex partners Early age (younger than 20) at first coitus (exposes the vulnerable young cervix to potential carcinogens from a partner) Early childbearing Exposure to human papillomavirus HIV infection Smoking Exposure to diethylstilbestrol (DES) in utero Low socioeconomic status (may be related to early marriage and early childbearing) Nutritional deficiencies (folate, beta-carotene, and vitamin C levels are lower in women with cervical cancer than in women without it) Chronic cervical infection Preventive Measures Regular pelvic examinations and Pap tests for all women, especially older women past childbearing age (decreases the chance of dying from cervical cancer from 1 in 250 to 1 in 2,000 women) Education related to reproductive health and safer sex Smoking cessation
and occurs usually after mild trauma or pressure (eg, intercourse, douching, or bearing down during defecation). As the disease continues, the bleeding may persist and increase. Leg pain, dysuria, rectal bleeding, and edema of extremities signal advanced disease. As the cancer advances, it may invade the tissues outside the cervix, including the lymph glands anterior to the sacrum. In one third of patients with invasive cervical cancer, the disease involves the fundus. The nerves in this region may be affected, producing excruciating pain in the back and the legs that is relieved only by large doses of opioid analgesic agents. If the disease progresses, it often produces extreme emaciation and anemia, usually accompanied by fever due to secondary infection and abscesses in the ulcerating mass, and by fistula formation. Because the survival rate for in situ cancer is 100% and the rate for women with more advanced stages of cervical cancer decreases dramatically, early detection is essential.
Assessment and Diagnostic Findings Diagnosis may be made on the basis of abnormal Pap smear results, followed by biopsy results identifying severe dysplasia (cervical intraepithelial neoplasia type III [CIN III], high-grade squamous intraepithelial lesions [HGSIL] [also referred to as HSIL], or carcinoma in situ; see below). HPV infections are usually implicated in these conditions. Biopsy results may indicate carcinoma in situ. Carcinoma in situ is technically classified as severe dysplasia and is defined as cancer that has extended through the full thickness of the epithelium of the cervix, but not beyond. This is often referred to as preinvasive cancer. In its very early stages, invasive cervical cancer is found microscopically by Pap smear. In later stages, pelvic examination may reveal a large, reddish growth or a deep, ulcerating lesion. The patient may report spotting or bloody discharge. When the patient has been diagnosed with invasive cervical cancer, clinical staging estimates the extent of the disease so that treatment can be planned more specifically and prognosis rea-
sonably predicted. The International Classification adopted by the International Federation of Gynecology and Obstetrics and included in the NIH Consensus Conference on Cervical Cancer (1996) (Table 47-2) is the most widely used staging system; the TNM (tumor, nodes, and metastases) classification is also used in describing cancer stages. In this system, T refers to the extent of the primary tumor, N to lymph node involvement, and M to metastasis, or spread of the disease. Signs and symptoms are evaluated, and x-rays, laboratory tests, and special examinations, such as punch biopsy and colposcopy, are performed. Depending on the stage of the cancer, other tests and procedures may be performed to determine the extent of disease and appropriate treatment. These tests include dilation and curettage (D & C), computed tomography (CT) scan, magnetic resonance imaging (MRI), intravenous urography, cystography, and barium x-ray studies.
Medical Management PRECURSOR OR PREINVASIVE LESIONS When precursor lesions, such as low-grade squamous intraepithelial lesion (LGSIL), which is also referred to as LSIL (CIN I and II or mild to moderate dysplasia), are found by colposcopy
Table 47-2
• International Classification of Carcinoma
STAGE OF LESION
Preinvasive Stage 0 Invasive Stage I Stage Ia Stage Ia1 Stage Ia2 Stage Ib Stage Ib1 Stage Ib2 Stage II Stage IIa Stage IIb Stage III
Stage IIIa Stage IIIb Stage IV Stage IVa Stage IVb
of the Uterine Cervix SIZE AND DESCRIPTION
Carcinoma in situ; cancer limited to epithelial layer; no evidence of invasion Carcinoma strictly confined to cervix Microinvasive; identified only microscopically Invasion no greater than 3 mm in depth and no wider than 7 mm Invasion > 3 mm and no greater than 5 mm and no wider than 7 mm Clinical lesions confined to cervix or preclinical lesions > stage Ia Clinical lesions no greater than 4 cm in size Clinical lesions > 4 cm in size Carcinoma extends beyond the cervix but not onto thepelvic wall Vaginal extension only Paracervical extension with or without vaginal involvement Carcinoma extends to one or both pelvic walls Involves lower third of vagina. One or both ureters obstructed by the tumor on IV urogram No extension onto the pelvic wall Extension onto the pelvic wall or hydronephrosis or nonfunctioning kidney, or both Extension of carcinoma beyond the true pelvis Clinical involvement of the mucosa of the bladder or rectum Spread of carcinoma to adjacent organs Spread to distant organs
National Institutes of Health (NIH) (1996). NIH Consensus Statement: Cervical Cancer. 14(1),1–38.
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and biopsy, careful monitoring by frequent Pap smears or conservative treatment is possible. Conservative treatment may consist of monitoring, cryotherapy (freezing with nitrous oxide), or laser therapy. A loop electrocautery excision procedure (LEEP) may also be used to remove abnormal cells. In this procedure, a thin wire loop with laser is used to cut away a thin layer of cervical tissue. LEEP is an outpatient procedure usually performed in a gynecologist’s office; it takes only a few minutes. Analgesia is given before the procedure, and a local anesthetic agent is injected into the area. This procedure allows the pathologist to examine the removed tissue sample to determine if the borders of the tissue are disease-free. Another procedure called a cone biopsy or conization (removing a cone-shaped portion of the cervix) is performed when biopsy findings demonstrate CIN III or HGSIL, equivalent to severe dysplasia and carcinoma in situ. If preinvasive cervical cancer (carcinoma in situ) occurs when a woman has completed childbearing, a hysterectomy is usually recommended. If a woman has not completed childbearing and invasion is less than 1 mm, a cone biopsy may be sufficient. Frequent re-examinations are necessary to monitor for recurrence. A newly developed procedure called a radical trachelectomy is an alternative to hysterectomy in women with cervical cancer who are young and want to have children (Dargent, Martin, Sacchetoni & Mathevet, 2000). In this procedure the cervix is gripped with retractors and pulled into the vagina until it is visible. The affected tissue is excised while the rest of the cervix and uterus remain intact. A drawstring suture is placed to close the cervix. Patients who have precursor or premalignant lesions need reassurance that they do not have invasive cancer. However, the importance of close follow-up is emphasized because the condition, if untreated for a long time, may progress to cancer. Patients with cervical cancer in situ also need to know that this is usually a slowgrowing and nonaggressive type of cancer that is not expected to recur after appropriate treatment. INVASIVE CANCER Treatment of invasive cervical cancer depends on the stage of the lesion, the patient’s age and general health, and the judgment and experience of the physician. Surgery and radiation treatment (intracavitary and external) are most often used. When tumor invasion is less than 3 mm, a hysterectomy is often sufficient. Invasion exceeding 3 mm usually requires a radical hysterectomy with pelvic node dissection and aortic node assessment. Stage 1B1 tumors are treated with radical hysterectomy and radiation. Stage 1B2 tumors are treated individually because no single correct course has been determined, and many variable options may be seen clinically (Chart 47-7). Frequent follow-up after surgery by a gynecologic oncologist is imperative because the risk of recurrence is 35% after treatment for invasive cervical cancer. Recurrence usually occurs within the first 2 years. Recurrences are often in the upper quarter of the vagina, and ureteral obstruction may be a sign. Weight loss, leg edema, and pelvic pain may be signs of lymphatic obstruction and metastasis. Radiation, which is often part of treatment to reduce recurrent disease, may be delivered by an external beam or by brachytherapy (method by which the radiation source is placed near the tumor) or both. The field to be irradiated and dose of radiation are determined by stage, volume of tumor, and lymph node involvement. Treatment can be administered daily for 4 to 6 weeks followed by one or two treatments of intracavitary radiation. Interstitial therapy may be used when vaginal placement has become impossible due to tumor or stricture.
Chart 47-7
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Surgical Procedures for Cervical Cancer
Surgical procedures that may be carried out to treat cervical cancer include the following: • Total hysterectomy—removal of the uterus, cervix, and ovaries • Radical hysterectomy—removal of the uterus, ovaries, fallopian tubes, proximal vagina, and bilateral lymph nodes through an abdominal incision (Note: “radical” indicates that an extensive area of the paravaginal, paracervical, parametrial, and uterosacral tissues is removed with the uterus.) • Radical vaginal hysterectomy—vaginal removal of the uterus, ovaries, fallopian tubes, and proximal vagina • Bilateral pelvic lymphadenectomy—removal of the common iliac, external iliac, hypogastric, and obturator lymphatic vessels and nodes • Pelvic exenteration—removal of the pelvic organs, including the bladder or rectum and pelvic lymph nodes, and construction of diversional conduit, colostomy, and vagina • Radical trachelectomy—removal of the cervix and selected nodes to preserve childbearing capacity in a woman of reproductive age with cervical cancer
Platinum-based agents are being used to treat advanced cervical cancer. They are often used in combination with radiation therapy, surgery, or both. Studies are ongoing to find the best approach to treat advanced cervical cancer. Vaginal stenosis is a frequent side effect of radiation. Sexual activity with lubrication is preventive, as is use of a vaginal dilator to avoid severe permanent vaginal stenosis. Some patients with recurrences of cervical cancer are considered for pelvic exenteration, in which a large portion of the pelvic contents is removed. Unilateral leg edema, sciatica, and ureteral obstruction indicate likely disease progression. Patients with these symptoms have advanced disease and are not considered candidates for this major surgical procedure. Surgery is often complex because it is performed close to the bowel, bladder, ureters, and great vessels. Complications can be considerable and include pulmonary emboli, pulmonary edema, myocardial infarction, cerebrovascular accident, hemorrhage, sepsis, small bowel obstruction, fistula formation, urinary obstruction of ileal conduit, bladder dysfunction, and pyelonephritis, most often in the first 18 months. Vein constriction must be avoided postoperatively. Patients with varicose veins or a history of thromboembolic disease may be treated prophylactically with heparin. Pneumatic compression stockings are prescribed to reduce the risk for deep vein thrombosis. Nursing care of these patients is complex and requires coordination and care by experienced health care professionals. This is a complex, extensive surgical procedure that is reserved for those with a high likelihood of cure.
PREGNANCY-RELATED NEOPLASM Hydatidiform mole is a type of gestational trophoblastic neoplasm that occurs in 1 in 1,000 pregnancies. Delayed menses with spotting is the most common sign. Hyperemesis and uterine enlargement beyond that expected for gestational dates are also indicative. Moles can be partial or complete. Complete moles are more likely to be associated with medical complications. Pregnancy-induced hypertension (formerly called preeclampsia), a pregnancy-related complex of symptoms that may include edema, hypertension, and proteinuria, may occur. Treatment consists of suction curettage followed by monitoring serial beta-human
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chorionic gonadotropin (HCG) levels, which usually take about 2.5 months to return to normal. This condition may recur. Moles can be invasive also. Choriocarcinoma, another gestational neoplasm that usually occurs in the postpartum period, is a placental site trophoblastic tumor. These malignancies are being diagnosed more readily and treated more effectively today due to the availability of testing for HCG, a sensitive marker that can be used for monitoring. Ultrasound is also used for making the diagnosis. These malignancies are usually found in obstetric patients and are described in detail in obstetric and oncologic textbooks. Nurses need to be aware that these conditions are traumatic, anxiety-producing, and often very stressful for the patient since they are often associated with pregnancy loss.
CANCER OF THE UTERUS (ENDOMETRIUM) Cancer of the uterine endometrium (fundus or corpus) has increased in incidence, partly because people are living longer and because reporting is more accurate. Most uterine cancers are endometrioid (that is, originating in the lining of the uterus). After breast, colorectal, and lung cancer, endometrial cancer is the fourth most common cancer in women and the most common pelvic neoplasm. Cumulative exposure to estrogen is considered the major risk factor (Chart 47-8). This exposure occurs with the use of estrogen replacement therapy without the use of progestin, early menarche, late menopause, never having children, and anovulation. Other risk factors include infertility, diabetes, hypertension, gallbladder disease, and obesity (American Cancer Society, 2002). Tamoxifen may also cause proliferation of the uterine lining, and women receiving this medication for treatment or prevention of breast cancer are monitored by their oncologists. Another less common type of cancer of the uterus is not estrogen-dependent and is found in multiparous, thin women.
gen; a thicker lining warrants further investigation.) A biopsy or aspiration is diagnostic.
Medical Management Treatment of endometrial cancer consists of total hysterectomy (discussed later in this chapter) and bilateral salpingo-oophorectomy and node sampling. Depending on the stage, the therapeutic approach is individualized and is based on stage, type, differentiation, degree of invasion, and node involvement. Whole pelvis radiotherapy is used if there is any spread beyond the uterus. Preoperative and postoperative treatments for stage II and beyond may include pelvic, abdominal, and vaginal intracavitary radiation. Recurrent cancer usually occurs inside the vaginal vault or in the upper vagina, and metastasis usually occurs in lymph nodes or the ovary. Recurrent lesions in the vagina are treated with surgery and radiation. Recurrent lesions beyond the vagina are treated with hormonal therapy or chemotherapy. Progestin therapy is used frequently. Patients should be prepared for such side effects as nausea, depression, rash, or mild fluid retention with this therapy.
CANCER OF THE VULVA Primary cancer of the vulva represents 3% to 5% of all gynecologic malignancies and is seen mostly in postmenopausal women, although its incidence in younger women is increasing. The median age for cancer limited to the vulva is 44 years, whereas the median age for invasive vulvar cancer is 61 years. Possible risk factors include hypertension, obesity, diabetes, and immunosuppression. Squamous cell carcinoma accounts for most primary vulvar tumors. Less common are Bartholin’s gland cancer and malignant melanoma. Little is known about what causes this disease; however, increased risk may be related to chronic vulvar irritation, vulvar disorders, HPV, and smoking.
Clinical Manifestations Assessment and Diagnostic Findings All women should be encouraged to have annual checkups, including a gynecologic examination. Any woman who is experiencing irregular bleeding should be evaluated promptly. If a menopausal or perimenopausal woman experiences bleeding, an endometrial aspiration or biopsy is performed to rule out hyperplasia, a possible precursor of endometrial cancer. The procedure is quick and painless. Ultrasonography can also be used to measure the thickness of the endometrium. (Postmenopausal women should have a very thin endometrium due to low levels of estro-
Chart 47-8
Risk Factors for Uterine Cancer • Age: at least 55 years; median age, 61 years • Postmenopausal bleeding • Obesity that results in increased estrone levels (related to excess weight) resulting from conversion of androstenedione to estrone in body fat, which exposes the uterus to unopposed estrogen • Unopposed estrogen therapy (estrogen used without progesterone, which offsets the risk of unopposed estrogen) • Other: nulliparity, truncal obesity, late menopause (after 52 years of age) and, possibly, use of tamoxifen
Long-standing pruritus and soreness are the most common symptoms of vulvar cancer. Itching occurs in half of all patients with vulvar malignancy. Bleeding, foul-smelling discharge, and pain may also be present and are usually signs of advanced disease. Cancerous lesions of the vulva are visible and accessible and grow relatively slowly. Early lesions appear as a chronic dermatitis; later, the patient may note a lump that continues to grow and becomes a hard, ulcerated, cauliflower-like growth. Biopsy should be performed on any vulvar lesion that persists, ulcerates, or fails to heal quickly with proper therapy. Vulvar malignancies may appear as a lump or mass, redness, or a lesion that fails to heal. The nurse is in an ideal position to encourage a woman to perform vulvar self-examination regularly. Using a mirror, the patient can see what constitutes normal female anatomy and learn about changes that should be reported (eg, lesions, ulcers, masses, and persistent itching). The nurse must urge women to seek health care if they notice anything abnormal because this is one of the most curable of all malignant conditions.
Medical Management Vulvar intraepithelial lesions are preinvasive and are also called vulvar carcinoma in situ. They may be treated by local excision, laser ablation, chemotherapeutic creams (ie, 5-fluorouracil), or cryosurgery.
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When invasive vulvar carcinoma exists, primary treatment may include wide excision or removal of the vulva (vulvectomy). An effort is made to individualize treatment, depending on the extent of the disease. A wide excision is performed only if lymph nodes are normal. More pervasive lesions require vulvectomy with deep pelvic node dissection. Vulvectomy is very effective at prolonging life but is frequently followed by complications (ie, scarring, wound breakdown, leg swelling, vaginal stenosis, or rectocele). To reduce complications, only necessary tissue is removed. Radiation is used to treat unresectable tumors or cancer that has spread to the lymph nodes. If a widespread area is involved or the disease is advanced, a radical vulvectomy with bilateral groin dissection may be performed. Excision and evaluation of the sentinel node, which drains the primary tumor, may be performed. If negative, full groin dissection may be omitted (Duffy, 2001). Antibiotic and heparin prophylaxis may be prescribed preoperatively and continued postoperatively to prevent infection, deep vein thrombosis, and pulmonary emboli. Elastic compression stockings are applied to reduce the risk for deep vein thrombosis. Clinical trials to determine the most effective treatment are difficult to conduct, as there are few patients with this condition. Morbidity with recurrence of the disease is high. Patterns can vary in patients.
NURSING PROCESS: THE PATIENT UNDERGOING VULVAR SURGERY Assessment The health history is a valuable tool for establishing rapport with the patient. The reason the patient is seeking health care is apparent. What the nurse can tactfully elicit is the reason why a delay, if any, occurred, in seeking health care—for example, because of modesty, economics, denial, neglect, or fear (abusive partners sometimes prevent women from seeking health care). Factors involved in any delay in seeking health care and treatment may also affect the patient’s recovery. The patient’s health habits and lifestyle are assessed, and her receptivity to teaching is evaluated. Psychosocial factors are also assessed. Preoperative preparation and psychological support begin at this time.
Diagnosis NURSING DIAGNOSES Based on all the assessment data, the patient’s major nursing diagnoses may include the following:
• Anxiety related to the diagnosis and surgery • Acute pain related to the surgical incision and subsequent wound care
• Impaired skin integrity related to the wound and drainage • Sexual dysfunction related to change in body image • Self-care deficit related to lack of understanding of perineal care and general health status
COLLABORATIVE PROBLEMS/ POTENTIAL COMPLICATIONS Based on assessment data, potential complications may include the following:
• Wound infection and sepsis • Deep vein thrombosis • Hemorrhage
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Planning and Goals The major goals for the patient may include acceptance of and preparation for surgical intervention, relief of pain, maintenance of skin integrity, recovery of optimal sexual function, ability to perform adequate and appropriate self-care, and absence of complications.
Preoperative Nursing Interventions RELIEVING ANXIETY The patient must be allowed time to talk and ask questions. Fear often decreases when a woman of childbearing age who is to undergo wide excision of the vulva or vulvectomy learns that the possibility for subsequent sexual relations is good and that pregnancy is possible after a wide excision. The nurse must know what information the physician has given the patient about the surgery to reinforce that information and address the patient’s questions and concerns. PREPARING SKIN FOR SURGERY Skin preparation may include cleansing the lower abdomen, inguinal areas, upper thighs, and vulva with a detergent germicide for several days before the surgical procedure. The patient may be instructed to do this at home.
Postoperative Nursing Interventions RELIEVING PAIN Because of the wide excision, the patient may experience severe pain and discomfort even with minimal movement. Inadequate pain relief will inhibit the patient’s mobility and increase the likelihood of complications. Therefore, analgesic agents are administered preventively (ie, around the clock at designated times) to relieve pain and increase the patient’s comfort level. Patient-controlled analgesia may be used to provide pain relief and promote patient comfort. Careful positioning using pillows usually increases comfort, as do soothing back rubs. A low Fowler’s position or, occasionally, a pillow placed under the knees will reduce pain by relieving tension on the incision; however, efforts must be made to avoid pressure behind the knees, which increases the risk for deep vein thrombosis. Positioning the patient on her side, with pillows between her legs and against the lumbar region, provides comfort and reduces tension on the surgical wound. IMPROVING SKIN INTEGRITY The patient may be confined to bed for several days to promote healing of the surgical and donor sites (if skin grafts were used). A pressure-reducing mattress may be used to prevent pressure ulcers. Moving from one position to another requires time and effort; use of an overbed trapeze bar may help the patient to move herself more easily. Ambulation may be attempted on the second day. The extent of the surgical incision and the type of dressing are considered when choosing strategies to promote skin integrity. Intact skin needs to be protected from drainage and moisture, and dressings must be changed as needed to ensure patient comfort, to perform wound care and irrigation (if prescribed), and to permit observation of the surgical site. When the patient returns from the operating room, perineal dressings are more likely to remain in place and be comfortable if a T-binder is used. A skin graft from the buttocks may have been performed if the edges of the excision could not be approximated, and drains may have been put in place as well. A pressure stent may be applied to
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the grafted site to promote adhesion. Nursing care includes monitoring for suppuration (accumulation of purulent material) under the graft and assisting the patient to keep the perineal area clean and dry. The wound is cleansed daily with warm, normal saline irrigations or other antiseptic solutions as prescribed. A transparent dressing or Xeroform gauze may be in place over the wound to minimize exposure to the air and subsequent pain. The appearance of the surgical site and the characteristics of drainage are assessed and documented. After the dressings are removed, a bed cradle may be used to keep the bed linens away from the surgical site. The nurse must protect the patient from exposure when visitors arrive or someone else enters the room. SUPPORTING POSITIVE SEXUALITY AND SEXUAL FUNCTION The patient who undergoes vulvar surgery usually experiences concerns about the effects of the surgery on her body image, sexual attractiveness, and functioning. Establishing a trusting nurse–patient relationship is important for the patient to feel comfortable expressing her concerns and fears. The patient is encouraged to share and discuss her concerns with her sexual partner. Because alterations in sexual sensation and functioning depend on the extent of surgery, the nurse needs to know about any structural and functional changes resulting from the surgery. Consulting with the surgeon will clarify which changes to expect, and referring the patient and her partner to a sex counselor may help them address these changes and resume satisfying sexual activity. MONITORING AND MANAGING POTENTIAL COMPLICATIONS Infection The location and extent of the surgical site and incision put the patient at risk for contamination of the site and infection and sepsis. The patient is monitored closely for local and systemic signs and symptoms of infection: purulent drainage, redness, increased pain, fever, and an increased white blood cell count. The nurse assists in obtaining tissue specimens for culture if infection is suspected and administers antibiotic agents as prescribed. Hand hygiene, always a crucial infection-preventing measure, is of particular importance whenever there is an extensive area of exposed tissue. Catheters, drains, and dressings are handled carefully and with gloves to avoid cross-contamination. A low-residue diet prevents straining on defecation and wound contamination. Sitz baths are discouraged after a wide excision because of the risk for infection. Deep Vein Thrombosis The patient is at risk for deep vein thrombosis because of the positioning required during surgery, postoperative edema, and the usually prolonged immobility needed to promote healing. Elastic compression stockings are applied, and the patient is encouraged and reminded to perform ankle exercises to minimize venous pooling, which leads to deep vein thrombosis. The patient is encouraged and assisted in changing position by using the overhead trapeze. Pressure behind the knees is avoided when positioning the patient because this may increase venous pooling. The patient is assessed for signs and symptoms of deep vein thrombosis (leg pain, redness, warmth, positive Homans’ sign) and pulmonary embolism (chest pain, tachycardia, dyspnea). Fluid intake is encouraged to prevent dehydration, which also increases the risk for deep vein thrombosis.
Hemorrhage The extent of the surgical incision and possibly wide excision of tissue increase the risk of postoperative bleeding and hemorrhage. Although the pressure dressings that are applied after surgery minimize the risk, the patient must be monitored closely for signs of hemorrhage and resulting hypovolemic shock. These signs may include decreased blood pressure, increased pulse rate, decreased urine output, decreased mental status, and cold, clammy skin. If hemorrhage and shock occur, interventions include fluid replacement, blood component therapy, and vasopressor medications. Laboratory results (eg, hematocrit and hemoglobin levels) and hemodynamic monitoring are used to assess the patient’s response to treatment. Depending on the specific cause of hemorrhage, the patient may be returned to the operating room. The patient who experiences hemorrhage is anxious and apprehensive. Providing brief explanations of the procedures being performed and offering reassurance that the problem has been identified and is being taken care of may reduce the anxiety and fears of the patient and her family. PROMOTING HOME AND COMMUNITY-BASED CARE Teaching Patients Self-Care Preparing the patient for hospital discharge begins before hospital admission. The patient and family are informed about what to expect during the immediate postoperative and recovery periods. Posthospital care requires giving complete instructions to a family member or significant other who will help care for the patient at home and to the home care nurse who will provide follow-up care. Depending on the changes resulting from the surgery, the patient and her family may need instruction about wound care, urinary catheterization, and possible complications. The patient is encouraged to share her concerns and to assume increasing responsibility for her own care. She is encouraged and assisted in learning to care for the surgical wound. Continuing Care Shortened hospital stays may result in the patient’s discharge during the early postoperative recovery stage. Thus, home care referral or discharge to a subacute facility may be indicated. During this phase, the patient’s physical status and psychological responses to the surgery are assessed. Additionally, the patient is assessed for complications and healing of the surgical site. During home visits, the patient’s environment is assessed to determine if modifications are needed to facilitate patient care. The home care nurse uses the home visit to reinforce previous teaching and to assess the patient’s and the family’s understanding of and adherence to the prescribed treatment strategies. Follow-up phone calls by the nurse to the patient between home visits are usually reassuring to the patient and family, who may be responsible for performing complex care procedures. Attention to the patient’s psychological responses is important because the patient may become discouraged and depressed because of alterations in body image and a slow recovery. Communication between the nurse involved in the patient’s immediate postoperative care and the home care nurse is essential to ensure continuity of care.
Evaluation EXPECTED PATIENT OUTCOMES Expected patient outcomes may include: 1. Adjusts to the trauma of the surgical experience a. Uses available resources in coping with and alleviating emotional stress
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4.
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Management of Patients With Female Reproductive Disorders
b. Asks questions related to postoperative expectations c. Demonstrates willingness to discuss alternative approaches to sexual expression Obtains pain relief a. Reports progressive decline in pain and discomfort b. Assumes position of comfort Maintains skin integrity a. States rationale for use of a special mattress or other device b. Uses overhead trapeze to change position frequently c. Exhibits healing of surgical site without excoriated skin d. Cares for incision and surgical site as instructed Exhibits positive outlook about sexuality and sexual functioning a. Verbalizes concerns and anxieties about sexual functioning b. Discusses options and alternative approaches to sexual intercourse Increases participation in self-care activities a. Demonstrates self-care activities as instructed b. Identifies signs and symptoms of complications that should be reported to the nurse or physician c. Properly cleans the surgical site after voiding and defecation Absence of complications a. Is free of any signs and symptoms of infection: has normal vital signs (temperature, blood pressure, pulse rate); has no purulent discharge b. Identifies activities to prevent deep vein thrombosis: avoids crossing legs or sitting with pressure against knees; exercises ankles and legs c. Exhibits no signs or symptoms of deep vein thrombosis (leg pain, redness, edematous or swollen extremities) d. Demonstrates no signs or symptoms of hemorrhage
CANCER OF THE VAGINA Cancer of the vagina usually results from metastasized choriocarcinoma or from cancer of the cervix or adjacent organs (eg, uterus, vulva, bladder, or rectum). Primary cancer of the vagina is squamous in origin. Risk factors include previous cervical cancer, in utero exposure to diethylstilbestrol (DES), previous vaginal or vulvar cancer, previous radiation therapy, history of HPV, or pessary use. Any patient with previous cervical cancer should be examined regularly for vaginal lesions. Before 1970, vaginal cancer occurred primarily in postmenopausal women. In the 1970s, it was shown that maternal ingestion of DES affected female offspring who were exposed in utero. Benign genital tract abnormalities have occurred in some of these young women. Vaginal adenosis (abnormal tissue growth) may also occur. The risk for clear cell tumor related to DES exposure is 0.14 to 1.4 in 1,000 women. Colposcopy is indicated for all women exposed to this medication in utero. If colposcopic examination discloses adenosis or a significant cervical lesion, follow-up is essential. Vaginal pessaries, used to support prolapsed tissues, have been associated with vaginal cancer only if the devices were not cared for properly (ie, regularly cleaned and the vagina examined by a health care professional) because pessaries can be a source of chronic irritation. Patients often do not have symptoms but may report slight bleeding after intercourse, spontaneous bleeding, vaginal dis-
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charge, pain, and urinary or rectal symptoms (or both). Diagnosis is often by Pap smear of the vagina.
Medical Management Treatment of early lesions may be local excision or administration of a chemotherapeutic cream (ie, 5-fluorouracil applied with a tampon or a diaphragm). Cotton balls placed at the introitus lessen spillage, which otherwise can result in perineal irritation. Laser therapy is a common treatment option in early vaginal and vulvar cancer. Radiation, another treatment option, is delivered by external beam to the pelvis, by vaginal intracavitary radiation using a tandem and colpostats, or by interstitial vaginal implants using an obturator and vaginal template. For a tumor located in the lower third of the vagina, radical node dissection is followed by radiation. Encouraging close follow-up by health care providers is the prime focus of nursing interventions with women who were exposed to DES in utero. Because DES was used only from the 1940s to the 1970s, the incidence will decrease with each subsequent year. Emotional support for mothers and daughters is essential. For young women who have had vaginal reconstructive surgery, specific vagina-dilating procedures may be initiated and taught. Water-soluble lubricants are helpful in reducing painful intercourse (dyspareunia). If a lesion requiring treatment develops, all aspects and effects of radiation therapy, chemotherapy, or surgery need to be explored on an individual basis.
CANCER OF THE FALLOPIAN TUBES Malignancies of the fallopian tube are rare and are the least common type of genital cancer. Symptoms include a profuse, watery discharge and a colicky lower abdominal pain or abnormal vaginal bleeding. An enlarged fallopian tube may be found on examination. Surgery followed by radiation therapy is the usual treatment.
CANCER OF THE OVARY Ovarian cancer causes more deaths than any other cancer of the female reproductive system. About 75% of cases are detected at a late stage (Duffy, 2001). The ovary is a common site of primary as well as metastatic lesions from other cancers. Most cases affect women ages 50 to 59. The incidence of ovarian cancer is highest in industrialized countries, except for Japan, where its incidence is low. A woman with ovarian cancer has a threefold to fourfold increased risk for breast cancer, and women with breast cancer have an increased risk for ovarian cancer. No definitive causative factors have been determined, but oral contraceptives appear to provide a protective effect. Heredity plays a part, and many physicians advocate pelvic examinations every 6 months for women who have one or two relatives with ovarian cancer. Despite careful examination, ovarian tumors are often difficult to detect because they are usually deep in the pelvis. No early screening mechanism exists at present, although tumor markers are being explored. Transvaginal ultrasound and Ca-125 antigen testing are helpful in those at high risk for this condition. Tumor-associated antigens are helpful in follow-up care after diagnosis and treatment but not in early general screening. Advances in our knowledge of genetics are changing the approaches to detecting and treating breast and ovarian cancer. Some families have specific genes that predispose them to various cancers. BRCA-1 is a genetic mutation that results in an increased
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risk for breast and ovarian cancer. BRCA-2 is another genetic mutation that may result in increased risk for both female and male breast cancers and for ovarian cancer (Duffy, 2001). Other mutations are also under study. Testing for susceptibility is in the early stages at centers that have expertise in genetics, testing, and counseling. Testing is indicated when a family history of three or more cases of closely related members includes premenopausal breast cancer or ovarian cancer. One member with cancer is tested, and if the results are positive, other members without cancer may undergo testing. Much more needs to be learned about the risks associated with some mutations, the reliability of testing, and the efficacy of follow-up. Confidentiality and insurance risks are ethical issues that need clarification. Because there are no primary methods of preventing breast or ovarian cancer, emotional distress is also a problem. Patients with concerns about their family history should be referred to a cancer genetics center to obtain information and testing, if indicated. Women with inherited types of ovarian cancer tend to be younger when the diagnosis is made than the average age of 59 years at the time of diagnosis. Risk factors also include nulliparity and infertility. Older age is a major risk factor because the incidence of this disease peaks in the eighth decade of life. High dietary fat intake, mumps before menarche, use of talc in the perineal area, and family history are suspected to increase risk, while multiparity, oral contraceptive use, breastfeeding, and anovulatory disorders may be protective. Survival rates depend on the stage of the cancer at diagnosis. Fifteen percent of all new cases of ovarian tumors have low malignancy potential (LMP tumors). These borderline tumors resemble ovarian cancer but have much more favorable outcomes. Women diagnosed with this type of cancer tend to be younger, in their early 40s. A conservative surgical approach is now used. The affected ovary is removed, but the uterus and the contralateral ovary may remain. Adjuvant therapy may not be warranted for these tumors.
Clinical Manifestations Symptoms are nonspecific and include increased abdominal girth, pelvic pressure, bloating, indigestion, flatulence, increased waist size, leg pain, and pelvic pain. Symptoms are often vague, and many women ignore the symptoms. Ovarian cancer is often silent, but enlargement of the abdomen from an accumulation of fluid is the most common sign. Any woman with gastrointestinal symptoms and without a known diagnosis must be evaluated with ovarian cancer in mind. Flatulence, fullness after a light meal, and increasing abdominal girth are significant symptoms. Vague, undiagnosed, persistent gastrointestinal symptoms should alert the nurse to the possibility of an early ovarian malignancy. A palpable ovary in a woman who has gone through menopause is investigated because ovaries normally become smaller and less palpable after menopause.
Assessment and Diagnostic Findings Any enlarged ovary must be investigated. Pelvic examination often does not detect early ovarian cancer, and pelvic imaging techniques are not always definitive. About 75% of ovarian cancers have metastasized by the time of diagnosis; about 60% have spread beyond the pelvis. Of the many different ovarian cancer cell types, epithelial tumors constitute 90%. Germ cell tumors and stromal tumors make up the other 10%.
Medical Management SURGICAL MANAGEMENT Surgical staging, exploration, and reduction of tumor mass are the basics of treatment. Surgical removal is the treatment of choice; the preoperative workup includes a barium enema or colonoscopy, upper gastrointestinal series, chest x-rays, and intravenous urography. CT scans and immunoscintigraphy, the use of radioactive antibodies, may be used preoperatively to rule out intra-abdominal metastasis. Staging the tumor is important to guide treatment (Chart 47-9). A total abdominal hysterectomy with removal of the fallopian tubes and ovaries and the omentum (bilateral salpingooophorectomy and omentectomy) is the standard procedure for early disease. PHARMACOLOGIC THERAPY Chemotherapy often follows surgery, usually with cyclophosphamide (Cytoxan), doxorubicin (Adriamycin), cisplatin (Platinol-AQ), carboplatin (Paraplatin), or paclitaxel (Taxol). Hexamethylmelamine (Hexalen), ifosfamide (Ifex), bone marrow transplantation, and peripheral blood stem cell support may also be used. Paclitaxel, cisplatin, and carboplatin are most often used because of their excellent clinical benefits and manageable toxicity. Leukopenia, neurotoxicity, and fever may occur. Paclitaxel, an agent derived from the Pacific yew tree, works by causing microtubules within the cells to gather and prevents the breakdown of these threadlike structures. In general, cells cannot function when they are clogged with microtubules and cannot divide. Because this medication often causes leukopenia, the patient may need to take granulocyte colony-stimulating factor as well. Paclitaxel is contraindicated in patients with hypersensitivity to medications formulated in polyoxyethylated castor oil and in patients with baseline neutropenia. Because of possible adverse cardiac effects, paclitaxel is not used in patients with cardiac disorders. Hypotension, dyspnea, angioedema, and urticaria indicate severe reactions that usually occur soon after the first and second doses are administered. The nurse must be prepared to assist in treating anaphylaxis. The patient should be prepared for inevitable hair loss. Cisplatin is used frequently in chemotherapeutic treatment of ovarian cancer, both alone and in combination with other agents, and in intraperitoneal applications. Patients may require bone marrow transplantation or stem cell transplantation to treat ovarian cancer. Care for these patients is described in Chapter 16. Intraperitoneal chemotherapy with cisplatin may provide a promising mode of treatment. Carboplatin may be used in the initial treatment of advanced ovarian cancer in combination with other chemotherapeutic agents. It may also be used in patients with recurrence of ovarian cancer after other chemotherapy, including cisplatin. It must be used with caution in patients with renal impairment.
Chart 47-9
Stages of Ovarian Cancer
I —Growth limited to the ovaries II —Growth involves one or both ovaries with pelvic extension III—Growth involves one or both ovaries with metastases outside the pelvis or positive retroperitoneal or inguinal nodes IV—Growth involves one or both ovaries with distant metastases
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Other medications include topotecan (Hycamtin), irinotecan (Camptosar), gemcitabine (Gemzar), vinorelbine (Navelbine), liposomal doxorubicin (Doxil), and docetaxel (Taxotere). Different combinations, different regimens, different routes, and use of growth factors are being investigated. Liposomal therapy, delivery of chemotherapy in a liposome, allows the highest possible dose of chemotherapy to the tumor target with a reduction in adverse effects. Liposomes are used as drug carriers because they are nontoxic, biodegradable, easily available, and relatively inexpensive. This encapsulated chemotherapy allows increased duration of action and better targeting. The encapsulation of doxorubicin lessens the incidence of nausea, vomiting, and alopecia. The patient must be monitored for bone marrow suppression. Gastrointestinal and cardiac effects may also occur. These medications are administered by oncology nurses as a slow intravenous infusion over 60 to 90 minutes. Genetic engineering and identification of cancer genes may make gene therapy a future possibility. Gene therapy is under investigation. Radiation may be helpful and is more useful in some types of ovarian cancer than others. After adjunct therapies are completed, a second-look laparoscopy or a laparotomy may be performed in some clinical centers to evaluate the treatment results and to obtain multiple tissue samples for biopsy. Occasionally, catheters are left in place if radioactive agents are to be used postoperatively. Chemotherapy is the most common form of treatment in advanced disease.
Nursing Management Nursing measures include those related to the patient’s treatment plan, be it surgery, chemotherapy, radiation, or palliation. Emotional support, comfort measures, and information, plus attentiveness and caring, are meaningful aids to the patient and her family. Nursing interventions after pelvic surgery to remove the tumor are similar to those after other abdominal surgeries. If ovarian cancer occurs in a young woman and the tumor is unilateral, it is removed. Childbearing, if desired, is encouraged in the near future. After childbirth, surgical re-exploration may be performed and the remaining ovary may be removed. If both ovaries are involved, surgery is performed and chemotherapy follows. Patients with advanced ovarian cancer may develop ascites and pleural effusion. Nursing care may include administering intravenous therapy to alleviate fluid and electrolyte imbalances, initiating parenteral nutrition to provide adequate nutrition, providing postoperative care after intestinal bypass to alleviate an obstruction, and providing pain relief and managing drainage tubes. These conditions are complex and often require assistance and support from an oncology nurse specialist. Comfort measures for women with ascites may include providing small frequent meals, decreasing fluid intake, administering diuretic agents, and providing rest. Patients with pleural effusion may experience shortness of breath, hypoxia, pleuritic chest pain, and cough. Thoracentesis is usually performed.
Hysterectomy A total hysterectomy involves removing the uterus and the cervix. This procedure is performed for many conditions other than cancer, including dysfunctional uterine bleeding, endometriosis, nonmalignant growths, pelvic relaxation and prolapse, and previous
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injury to the uterus. Malignant conditions often require a total abdominal hysterectomy and bilateral salpingo-oophorectomy (removal of fallopian tubes and ovaries). Laparoscopically assisted hysterectomy is performed by some physicians with excellent results and rapid recovery. This method is most often used for vaginal hysterectomy and is performed as a short-stay procedure or ambulatory surgery in carefully selected patients. Patients have a short hospital stay and a low incidence of postoperative infection. The number of hysterectomies in the United States per year has stabilized at 600,000, despite an increase in the number of babyboomers who have reached the age when this procedure is likely to be performed. The rate may be stabilizing because women often seek second opinions, and the number of therapeutic options (ie, laser therapy, endometrial ablation, and medications to shrink fibroid tumors) has increased.
PREOPERATIVE MANAGEMENT The physical preparation of a patient undergoing a hysterectomy differs little from that of a patient undergoing a laparotomy. The lower half of the abdomen and the pubic and perineal regions may be shaved, and these areas are cleaned with soap and water (some surgeons do not require that the patient be shaved). The intestinal tract and the bladder need to be empty before the patient is taken to the operating room to prevent contamination and injury to the bladder or intestinal tract. An enema and antiseptic douche may be prescribed the evening before surgery, and the patient may be instructed to administer these treatments at home. Preoperative medications administered before surgery may help the patient relax.
POSTOPERATIVE MANAGEMENT The principles of general postoperative care for abdominal surgery apply, with particular attention given to peripheral circulation to prevent thrombophlebitis and deep vein thrombosis (noting varicosities, promoting circulation with leg exercises, and using elastic compression stockings). Major risks are infection and hemorrhage. In addition, because the surgical site is close to the bladder, voiding problems may occur, particularly after a vaginal hysterectomy. Edema or nerve trauma may cause temporary loss of bladder tone (bladder atony), and an indwelling catheter may be inserted. During surgery, the handling of the bowel may cause paralytic ileus and interfere with bowel functioning.
NURSING PROCESS: THE PATIENT UNDERGOING A HYSTERECTOMY Assessment The health history and the physical and pelvic examination are completed, and laboratory studies are performed. Additional assessment data include the patient’s psychosocial responses, because the need for a hysterectomy may elicit strong emotional reactions. If the hysterectomy is performed to remove a malignant tumor, anxiety related to fear of cancer and its consequences adds to the stress of the patient and her family. These women may be at greater risk for psychological symptoms, physical symptoms, postmenopausal syndrome, and increased use of health care
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postoperatively. Other women note improved physical and mental health after hysterectomy.
Diagnosis NURSING DIAGNOSES Based on all the assessment data, the patient’s major nursing diagnoses may include the following:
• Anxiety related to the diagnosis of cancer, fear of pain, possible perception of loss of femininity, and disfigurement
• Disturbed body image related to altered fertility and fears about sexuality and relationships with partner and family
• Acute pain related to surgery and other adjuvant therapy • Deficient knowledge of the perioperative aspects of hysterectomy and postoperative self-care
COLLABORATIVE PROBLEMS/POTENTIAL COMPLICATIONS Based on assessment data, potential complications may include the following:
• Hemorrhage • Deep vein thrombosis • Bladder dysfunction Planning and Goals The major goals for the patient may include relief of anxiety, acceptance of loss of the uterus, absence of pain or discomfort, increased knowledge of self-care requirements, and absence of complications.
Nursing Interventions RELIEVING ANXIETY Anxiety stems from several factors: unfamiliar environment, the effects of surgery on body image and reproductive ability, fear of pain and other discomfort, and, possibly, feelings of embarrassment about exposure of the genital area in the perioperative period. Conflicts between medical treatment and religious beliefs may arise as well. In such cases, the nurse needs to determine what the experience means to the patient and how to assist her in expressing her feelings. Throughout the pre- and postoperative and recovery periods, explanations are given about physical preparations and procedures that are performed. Patient education addresses the outcomes of surgery, possible feelings of loss, and options for management of symptoms of menopause. Women vary in their preferences; many want a choice of treatment options, a part in decision making, accurate and useful information at the appropriate time, support from their health care providers, and access to professional and lay support systems. Recent findings from the Women’s Health Initiative study of hormone replacement therapy (HRT) have indicated that HRT does not have long-term cardiac benefits and may increase the risk for breast cancer. Although HRT has positive effects on bone density in women, many clinicians and women have concluded that the risks of HRT outweigh the benefits. However, some believe that short-term use of HRT (5 years or less) may be used to treat menopausal symptoms (Women’s Health Initiative, 2002). If the patient is considering beginning HRT, risks and benefits are discussed preoperatively and medication is started following surgery. Teaching is provided and the need for monitoring is emphasized.
IMPROVING BODY IMAGE The patient may have strong emotional reactions to having a hysterectomy and strong personal feelings related to the diagnosis, views of significant others who may be involved (family, partner), religious beliefs, and fears about prognosis. Concerns such as the inability to have children and the effect on femininity may surface, as may questions about the effects of surgery on sexual relationships, function, and satisfaction. The patient needs reassurance that she will still have a vagina and that she can experience sexual intercourse after a temporary postoperative abstinence while tissues heal. Information that sexual satisfaction and orgasm arise from clitoral stimulation rather than from the uterus reassures many women. Most women note some change in sexual feelings after hysterectomy, but they vary in intensity. In some cases, the vagina is shortened by surgery, and this may affect sensitivity or comfort. When a woman’s hormonal balance is upset, as usually occurs in reproductive system disturbances, the patient may experience depression and heightened emotional sensitivity to people and situations. The nurse needs to approach and evaluate each patient individually in light of these factors. The nurse who exhibits interest, concern, and willingness to listen to the patient’s fears will assist in the patient’s progress throughout the surgical experience. RELIEVING PAIN A hysterectomy may be performed abdominally or vaginally. The surgeon bases this decision on the diagnosis and the size of the uterus. An abdominal approach is used when the patient has cancer or when the uterus is enlarged. Resultant pain and abdominal discomfort are common. Analgesic agents are administered as prescribed to relieve pain and promote movement and ambulation. In some circumstances, a nasogastric tube may be inserted before the patient leaves the operating room to relieve discomfort from abdominal distention, especially if excessive handling of the viscera was required or if a large tumor was removed. Excision of a large tumor could cause edema because of the sudden release of pressure. In the postoperative period, fluids and food may be restricted for 1 or 2 days. If the patient has abdominal distention or flatus, a rectal tube and application of heat to the abdomen may be prescribed. When abdominal auscultation reveals return of bowel sounds and peristalsis, additional fluids and a soft diet are permitted. Early ambulation facilitates the return of normal peristalsis. MONITORING AND MANAGING POTENTIAL COMPLICATIONS Hemorrhage Vaginal bleeding and hemorrhage may occur after hysterectomy. To detect these complications early, the nurse counts the perineal pads used, assesses the extent of saturation with blood, and monitors vital signs. Abdominal dressings are monitored for drainage if an abdominal surgical approach was used. In preparation for hospital discharge, the nurse gives prescribed guidelines for activity restrictions to promote healing and to prevent postoperative bleeding. Deep Vein Thrombosis Because of positioning during surgery, postoperative edema, and immobility, the patient is at risk for deep vein thrombosis and pulmonary embolus. To minimize the risk, elastic compression stockings are applied. Additionally, the patient is encouraged and assisted to change positions frequently, although pressure under
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the knees is avoided. The nurse assists the patient to ambulate early in the postoperative period, and the patient is encouraged to exercise her legs and feet while in bed. Additionally, the nurse assesses for deep vein thrombosis or phlebitis (leg pain, redness, warmth, positive Homans’ sign) and pulmonary embolism (chest pain, tachycardia, dyspnea). Because the patient may be discharged within 1 or 2 days of surgery, she is instructed to avoid prolonged sitting in a chair with pressure at the knees, sitting with crossed legs, and inactivity. Bladder Dysfunction Because of possible difficulty in voiding postoperatively, an indwelling catheter may be inserted before or during surgery and is left in place in the immediate postoperative period. If a catheter is in place, it is usually removed shortly after the patient begins to ambulate. After the catheter is removed, urinary output is monitored; additionally, the abdomen is assessed for distention. If the patient does not void within a prescribed time, measures are initiated to encourage voiding (eg, assisting the patient up to the bathroom, pouring warm water over the perineum). If the patient cannot void, catheterization may be necessary. PROMOTING HOME AND COMMUNITY-BASED CARE Teaching Patients Self-Care The information provided to the patient is tailored to her needs. She must know what limitations or restrictions, if any, to expect. She is instructed to check the surgical incision daily and to contact her primary health care provider if redness or purulent drainage or discharge appears. She is informed that her periods are now over but that she may have a slightly bloody discharge for a few days; if bleeding recurs after this time, it should be reported immediately. The patient is instructed about the importance of an adequate oral intake and of maintaining bowel and urinary tract function. The patient is informed that postoperative fatigue may occur but that it should gradually decrease. The patient should resume activities gradually. This does not mean sitting for long periods, because doing so may cause blood to pool in the pelvis, increasing the risk for thromboembolism. The nurse explains that showers are preferable to tub baths to reduce the possibility of infection and to avoid the dangers of injury that may occur when getting in and out of the bathtub. The patient is instructed to avoid straining, lifting, having sexual intercourse, or driving until her surgeon permits her to resume these activities. Vaginal discharge, foul odor, excessive bleeding, any leg redness or pain, or an elevated temperature should be reported to her primary health care provider promptly. The nurse should be familiar with information given to the patient by the surgeon regarding all activities and restrictions to reinforce them and prevent confusion. Continuing Care Follow-up telephone contact provides the nurse with the opportunity to determine whether the patient is recovering without problems and to answer any questions that may have arisen. The patient is reminded about postoperative follow-up appointments. If the patient’s ovaries were removed, HRT may be considered. Providing information about the findings of the Women’s Health Initiative (2002) study about the benefits and risks of HRT promotes informed decision making about its use. The patient is reminded to discuss HRT and alternative therapies with her primary care provider.
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Evaluation EXPECTED PATIENT OUTCOMES Expected patient outcomes may include: 1. Experiences decreased anxiety 2. Has improved body image a. Discusses changes resulting from surgery with her partner b. Verbalizes understanding of her disorder and the treatment plan c. Displays minimal depression or sadness 3. Experiences minimal pain and discomfort a. Reports relief of abdominal pain and discomfort b. Ambulates without pain 4. Verbalizes knowledge and understanding of self-care a. Practices deep-breathing, turning, and leg exercises as instructed b. Increases activity and ambulation daily c. Reports adequate fluid intake and adequate urinary output d. Identifies reportable symptoms e. Schedules and keeps follow-up appointments 5. Absence of complications a. Has minimal vaginal bleeding and exhibits normal vital signs b. Ambulates early c. Notes no chest or calf pain and no redness, tenderness, or swelling in the extremities d. Reports no urinary problems or abdominal distention
Radiation Therapy Radiation is usually the treatment of choice for squamous cell carcinoma of the cervix, depending on the stage of the cancer. In uterine and ovarian cancers, however, radiation is usually an adjunct to surgery. When radiation is the definitive treatment of cervical cancer, a combination of external pelvic irradiation and internal (intracavitary) irradiation may be used. Only in the earliest microinvasive carcinomas of the cervix is intracavitary irradiation used alone. High cure rates can be expected with cervical cancer limited to the cervix. As the disease extends into the parametrium, the cure rate decreases. Once the disease extends to the pelvic side walls, however, perhaps only one third of patients are cured, although many more benefit from the palliative effects of radiation (ie, reduction in tumor bulk and control of infection, pain, and bleeding).
SIDE EFFECTS OF RADIATION THERAPY Radiation side effects are cumulative and tend to appear when the total dose exceeds the body’s natural capacity to repair the damage caused by radiation. Radiation enteritis, resulting in diarrhea and abdominal cramping, and radiation cystitis, manifested by urinary frequency, urgency, and dysuria, may occur. These effects are manifestations of the normal tissues’ response to radiation therapy. Occasionally, severe reactions require interrupting treatment until normal tissue repair occurs. Fatigue is one of the most bothersome side effects and is often not relieved by rest. The radiation oncologist and nurse must carefully inform the patient in advance about possible side effects and implement management strategies if they occur. Such measures include dietary control (restricting the amount of fiber, roughage, and lactose) and the use of antispasmodic medications. The purpose of
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a low-residue diet is to prevent frequent bowel movements and to avoid blockage resulting from possible constriction of the gastrointestinal tract. An oncology dietitian may be consulted. Evaluating the patient’s and family’s physical, emotional, and learning needs is part of the nursing assessment before and during treatment. Information overload, along with anxiety that impairs learning, must be anticipated. Any method of therapy requires adequate preparation, education, and emotional support. The patient who has been adequately prepared, supported, and educated before treatment through expert nursing care will find it easier to cope with the rigors and stress of cancer and its treatment.
METHODS OF RADIATION THERAPY Several approaches are used to deliver radiation to the female reproductive system: external radiation, intraoperative radiation therapy (IORT), and internal (intracavitary) irradiation or brachytherapy. The cervix and uterus lend themselves naturally to internal irradiation because they can serve as a receptacle for radioactive sources.
External Radiation Therapy This method of delivering radiation destroys cancerous cells at the skin surface or deeper in the body. Other methods of delivering radiation therapy are more commonly used to treat cancer of the female reproductive system than this method.
Intraoperative Radiation Therapy IORT allows radiation to be applied directly to the affected area during surgery. An electron beam is directed at the disease site. This direct-view irradiation may be used when para-aortic nodes are involved or for unresectable (inoperable) or partially resectable neoplasms. Benefits include accurate beam direction (which precisely limits the radiation to the tumor) and the ability during treatment to block sensitive organs from radiation. IORT is usually combined with external-beam irradiation preoperatively or postoperatively.
placed through the dilated endocervical canal into the uterine cavity, which remains in a fixed relationship with the irradiators placed in the upper vagina on each side of the cervix (vaginal ovoids) (Fig. 47-8). When the applicator is inserted, an indwelling urinary catheter is also inserted. Vaginal packing is inserted to keep the applicator in place and to keep other organs, such as the bladder and rectum, as far from the radioactive source as possible. The objective of the internal treatment is to maintain the distribution of internal radiation at a fixed dosage throughout the application. Such applications usually last 24 to 72 hours, depending on dose calculations made by the radiation physicist. Automated high-dose-rate intracavitary brachytherapy systems have been developed that allow outpatient radiation therapy. Treatment time is shorter, thereby decreasing patient discomfort. Staff exposure to radiation is also avoided. Isotopes of radium and cesium are used for intracavitary irradiation. NURSING CONSIDERATIONS FOR RADIATION SAFETY Various radioactive elements are used in intracavitary therapy. Regardless of the specific agent used, diligent nursing care must be provided. The patient is carefully observed and care is provided; however, the nursing staff must minimize radiation exposure to themselves as much as possible by applying the principles of time, distance, and shielding, as follows:
• Minimize amount of time near a radioactive source. • Maximize distance from radioactive source. • Use required shielding to minimize exposure. Nurses who are or may be pregnant should not be involved in the immediate care of such patients. Nursing visits to the patient should be planned in advance to minimize the amount of time the nurse is in contact with the patient. Additionally, to minimize radiation exposure, the nurse remains as far away (ie, at the entrance to the room) from the radiation source as possible but makes special efforts to provide some time to discuss the patient’s anxieties and fears. The Radiation Safety Department will give specific safety precautions to those who will be in contact with the patient, including health care providers and family. Nurses caring for the patient
Internal (Intracavitary) Irradiation The patient receives an anesthetic agent and is examined, after which specially prepared applicators are inserted into the endometrial cavity and vagina. These devices are not loaded with radioactive material until the patient returns to her room. X-rays are obtained to verify the precise relationship of the applicator to the normal pelvic anatomy and to the tumor. Only when this step is completed does the radiation oncologist load the applicators with predetermined amounts of radioactive material. This procedure, called afterloading, allows for precise control of the radiation exposure received by the patient, with minimal exposure of the physician, nurse, and other health care personnel. A patient undergoing internal radiation treatment remains isolated in a private room until the application is completed. Adjacent rooms may need to be evacuated and a lead shield placed at the doorway to the patient’s room. Of the various applicators developed for intracavitary treatment, some are inserted into the endometrial cavity and endocervical canal as multiple small irradiators (eg, Heyman’s capsules). Others consist of a central tube (a tandem or intrauterine “stem”)
Tandem Ovoid
Uterus Cervix Vagina
FIGURE 47-8 therapy.
Placement of tandem and ovoids for internal radiation
Chapter 47
Management of Patients With Female Reproductive Disorders
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will receive directions about safe times and distances related to care provision to ensure that their occupational exposure is as low as reasonably achievable (ALARA). Other instructions vary but may include the following:
local or general anesthesia and is performed in the patient’s room. Medicating the patient with a mild sedative agent may be required, however, before the applicator is removed.
• Wear film badges or pocket ion chambers to monitor
POST-TREATMENT CARE Progressive ambulation is recommended after any period of enforced bed rest. Diet may be offered as tolerated. The patient may shower as soon as she wishes but should be instructed not to douche after removal of the applicator. Because the cervix may have been dilated, any chance of bacterial contamination should be minimized. Both before and after treatment, nurses caring for patients undergoing radiation therapy need to assess any misconceptions about this mode of treatment that the patient and family may have. The oncology clinical nurse specialist may be a valuable resource for information and problem solving, if necessary. Resources for further clinical and patient information are listed at the end of Chapter 16.
exposure.
• Wear rubber gloves to dispose of any soiled matter that may • • •
be contaminated. (These gloves, however, do not provide protection from sealed radiation sources.) Provide specific laundry and housekeeping directions. Keep the patient restricted to her room and allow no visitors who are or may be pregnant or who are younger than 18 years of age. Explain that a discharge survey is usually performed by Radiation Safety Department personnel before the patient leaves the room. The survey ensures that all sources of radiation have been removed.
NURSING PRIORITIES FOR PATIENT CARE Of the many nursing concerns, primary concerns involve providing the patient with emotional support and physical comfort and not dislodging the applicator. Although the radiation oncologist takes steps to secure the internal applicator in place and nursing personnel need not be preoccupied with the fear that the applicator will be prematurely extruded, they should monitor to see that the applicator or the radioactive sources have not been dislodged. Should this happen, the nurse should avoid touching the radioactive object and notify the Radiation Safety Department at once. The nurse needs to explain that during the treatment, the patient must stay on absolute bed rest. She may move from side to side with her back supported by a pillow, and the head of the bed may be raised to 15 degrees. She should be encouraged to practice deep-breathing and coughing exercises and to flex and extend the feet to stretch the calf muscles, promoting circulation and venous return. Elastic compression stockings are important. Back care, though appreciated by the patient, needs to be performed within the minimal time allowed at the bedside. Usually the patient receives a low-residue diet to prevent frequent bowel movements. In addition, a urinary catheter will be in place and must be inspected frequently to ensure that it drains properly. The chief hazard of improper drainage is that the bladder may become distended and its walls exposed to radiation. Although perineal care is not performed at this time, any profuse discharge should be reported immediately to the radiation oncologist or gynecologic surgeon. Additional nursing interventions include observing the patient for temperature elevation, nausea, and vomiting. These symptoms should be reported because they may indicate such complications as infection or perforation. Patient teaching includes informing the patient that abdominal fullness, cramping, backache, and the urge to void are normal feelings during therapy. Severe pain should not occur. Administering mild opioid agents, muscle relaxants, or sedative medications may be helpful. APPLICATOR REMOVAL The radiation oncologist calculates precisely the radiation dose. At the end of the prescribed period, the nurse may be requested to assist the physician in removing the applicator. Because the sources are afterloaded, they can be removed by the physician in the same manner as they were inserted. This does not require
?
Critical Thinking Exercises
1.
Your 42-year-old patient has not received gynecologic care for the last 15 years but is currently seeking care for intermittent vaginal bleeding. When obtaining a history from her, you learn that her mother received diethylstilbestrol (DES) during her pregnancies. What implications does this have for care and follow-up of this patient?
2.
A 22-year-old graduate student seeks care because of severe pelvic pain, fever, and vaginal discharge. She reports having multiple sex partners and says she never uses a condom during sex because she uses oral contraceptives. Her physician has informed her that her symptoms are those of pelvic inflammatory disease (PID), and she is admitted to the hospital for intravenous antibiotic agents. What nursing care is important for her to minimize the risk for complications and to prevent transmission to others? Design a teaching plan to address the short- and long-term implications of the diagnosis of PID.
3.
Your 48-year-old patient is scheduled for a total hysterectomy. She tells you that she has a family history of breast cancer and both her mother and sister have osteoporosis. She asks you for advice about beginning hormone replacement therapy (HRT) because of her osteoporosis risk and to prevent hot flashes. How would you proceed, and what information would you give her?
4.
A 68-year-old woman is undergoing surgery to treat cervical cancer. While she is in the operating room, her husband reveals his concerns that he and his wife will never be able to have sexual relations again because of her diagnosis and treatment. What approach would you take in discussing this with the patient and with her husband?
5.
A 45-year-old woman is scheduled for surgery to repair a rectovaginal fistula. Twenty years ago she experienced a spinal cord injury that resulted in paralysis below the waist. Explain how you will modify pre- and postoperative nursing care in view of her disability. What discharge planning will be important for her?
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REFERENCES AND SELECTED READINGS Books ACOG (2001). Compendium of Selected Publications. Washington, DC: Author. American Cancer Society. (2002). Cancer facts and figures. Atlanta: Author. Barakat, R., Bevers, M., Gershenson, D., & Hoskins, W. (2000). M. D. Anderson Cancer Center and Memorial Sloan-Kettering Cancer Center handbook of gynecologic oncology. London: Dunitz. Emans, J., Laufer, M., & Goldstein, D. (1998). Pediatric and adolescent gynecology (4th ed.). Philadelphia: Lippincott-Raven. Goldman, J., & Hatch, M. (Eds.) (2000). Women and health. San Diego: Academic Press. Holmes, K. K., Maidli, P. A., et al. (2000). Sexually transmitted diseases. New York: McGraw-Hill. Kiviat, N., Kousky, L. A., et al. (2000). In K. K. Holmes, P. A. Maidli, et al. Sexually transmitted diseases. New York: McGraw-Hill. Lenhard, R., Osteen, R., & Gansler, T. (2001). American Cancer Society’s clinical oncology. Atlanta: American Cancer Society. Moore-Higgs, G. (2000). Women and cancer (2nd ed.). Sudbury: Jones and Bartlett. U.S. Surgeon General (2001). The Surgeon General’s call to action to promote sexual health and responsible sexual behavior. Washington, DC: U.S. Department of Health and Human Services.
Journals Asterisks indicate nursing research articles. General Centers for Disease Control and Prevention (CDC) (2002). Sexually transmitted diseases treatment guidelines, 2002. MMWR, Morbidity and Mortality Weekly Report, 51(RR-6), 1–85. *Czerwinski, B. (2000). Variation in feminine hygiene practices as a function of age. JOGNN, 29(6), 625–633. Nelson, H. D., Hymprey, L. L., Nygren, P. et al. (2002). Postmenopausal hormone replacement therapy: Scientific review. Journal of the American Medical Association, 288(7), 872–881. Rein, D., Kasler, W., Irwin, K., & Rabiee, L. (2000). Direct medical cost of pelvic inflammatory disease and its sequelae: Decreasing but still substantial. Obstetrics & Gynecology, 95(3), 397–402. Templeman, C., Fallat, M., Blinchevsky, A., & Hertweck, P. (2000). Noninflammatory ovarian masses in girls and young women. Obstetrics & Gynecology, 96(2), 229–233. VanZandt, S. (2000). Pelvic pain in women. Clinician Reviews, 10(9), 51–64. Women’s Health Initiative (2002). Risks and benefits of estrogen plus progestin in healthy postmenopausal women: Principal results from the Women’s Health Initiative randomized controlled trial. Journal of the American Medical Association, 288(3), 321–333. Benign Vulvar Disorders Haefner, H., & Pearlman, J. (1999). Diagnosing and managing vulvodynia. Contemporary Obstetrics & Gynecology, 44(2), 110–121. Scrimmin, F., Rustja, S., Radillo, O., et al. (2000). Vulvar lichen sclerosus: An immunologic study. Obstetrics & Gynecology, 95(1), 147–150. Endometriosis American College of Obstetricians and Gynecologists. ACOG Committee on Practice Bulletins (2000). Medical management of endometriosis. International Journal of Gynaecology & Obstetrics, 71(2), 183–96. Olive, D. L., & Pritts, E. A. (2001). Treatment of endometriosis. New England Journal of Medicine, 345(4), 266–275. Propst, A., & Laufer, M. (1999). Diagnosing and treating adolescent endometriosis. Contemporary Obstetrics & Gynecology, 44 (12), 52–59. Winkel, C. (1999). Laparoscopy plus GnRH analogs: A practical approach to endometriosis. Contemporary Obstetrics & Gynecology, 44(4), 99–109. Fibroids/Myomas Chiaffarino, F., Parazzini, F., laVecchia, C., Chatenoud, L., & DeCintio, E. (1999). Diet and uterine myomas. Obstetrics & Gynecology, 94(3), 395–402.
Lethaby, A., Vollenhoven, B., & Sowter, M. (2000). Pre-operative gonadotropin-releasing hormone analogue before hysterectomy or myomectomy for uterine fibroids. The Cochrane Library, Issue 2: Oxford. Lethaby, A., Shepperd, S., Cooke, I., & Farquhar, C. (2000). Endometrial resection and ablation versus hysterectomy for heavy menstrual bleeding. The Cochrane Library, Issue 2: Oxford. Stringer, N. (2000). Pirfenidone and tibolone: Innovations in drug therapy for uterine fibroids. Female Patient, 25(5), 12–18. Gynecologic Cancers (General) Chan, Y. M., Ngan, H. Y., Yip, P. S., et al. (2001). Psychosocial adjustment in gynecologic cancer survivors: A longitudinal study on risk factors for maladjustment. Gynecologic Oncology, 80(3), 387–394. Chan, Y. M., Ngan, H. Y., Li, B. Y., et al. (2001). A longitudinal study on quality of life after gynecologic cancer treatment.Gynecologic Oncology, 83(1), 10–19. *Chan, C. W., Molassiotis, A., Yam, B. M., et al. (2001). Traveling through the cancer trajectory: Social support perceived by women with gynecologic cancer in Hong Kong. Cancer Nursing, 24(5), 387–394. Dargent, D. F. (2001). Laparoscopic surgery in gynecologic oncology. Surgical Clinics of North America, 81(4), 949–964. Dargent, D., Martin, X., Sacchetoni, A., & Mathevet, P. (2000). Laparoscopic vaginal radical trachelectomy: A treatment to preserve the fertility of cervical carcinoma patients. Cancer, 88(8), 1877–1882. Duffy, M. S. (2001). Recent surgical approaches to gynecologic oncology. Nursing Clinics of North America, 36(3), 603–615. *Foxall, M. J., Barron, C. R., & Houfek, J. F. (2001). Ethnic influences on body awareness, trait anxiety, perceived risk, and breast and gynecologic cancer screening practices. Oncology Nursing Forum, 28(4), 727–738. Grigsby, P. W. (2002). Vaginal cancer. Current Treatment Options in Oncology, 3(2), 125–130. *Kwekkeboom, K. L. (2001). Pain management strategies used by patients with breast and gynecologic cancer with postoperative pain. Cancer Nursing, 24(5), 378–386. Mendez, L. E. (2001). Iatrogenic injuries in gynecologic cancer surgery. Surgical Clinics of North America, 81(4), 897–923. Nordin, A. J., Chinn, D. J., & Moloney, I., et al. (2001). Do elderly cancer patients care about cure? Attitudes to radical gynecologic oncology surgery in the elderly. Gynecologic Oncology, 81(3), 447–455. Pasacreta, J. V., Jabobs, L. & Cataldo, J. K. (2002). Genetic testing for breast and ovarian cancer risk: The psychosocial issues. American Journal of Nursing, 102(12), 40–47. Pignata, S., Ballatori, E., Favalli, G., & Scambia, G. (2001). Quality of life: Gynaecological cancers. Annals of Oncology, 12(Suppl 3), S37S42. Plante, M., & Roy, M. (2001). New approaches in the surgical management of early-stage cervical cancer. Current Opinion in Obstetrics and Gynecology, 13(1), 41–46. Sevin, B. U., & Koechli, O. R. (2001). Pelvic exenteration. Surgical Clinics of North America, 81(4), 771–779. Shepherd, J. H., Mould, T., & Oram, D. H. (2001). Radical trachelectomy in early-stage carcinoma of the cervix: Outcome as judged by recurrence and fertility rates. BJOG: International Journal of Obstetrics & Gynaecology, 108(8), 882–885. Swisher, E. M., Cohn, D. E., Goff, B. A., et al. (2002). Use of complementary and alternative medicine among women with gynecologic cancers. Gynecologic Oncology, 84(3), 363–367. *Velji, K., & Fitch, M. (2001). The experience of women receiving brachytherapy for gynecologic cancer. Oncology Nursing Forum, 28(4), 743–751. Herpes Burkhart, C., & Burkhart, K. (2000). Primary care update: Brief summaries for clinical practice. How to cope with genital herpes. Consultant, 40(7), 1298–1301. McClain, N., Cheung, K., Giardet, R., et al. (2000). Practice guidelines: Screening and treatment of sexually transmitted diseases:
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Part 2: trichomonas, human papillomavirus infection and genital herpes simplex virus. Journal of Pediatric Health Care, 14(3), 130–132. Swanson, J. (1999). The biopsychosocial burden of genital herpes: evidence-based and other approaches to care. Dermatology Nursing, 11(4), 257–270. Swanson, J., Dibble, S., & Chapman, L. (1999). Effects of psychoeducational interventions on sexual health risks and psychosocial adaptation in young adults with genital herpes. Journal of Advanced Nursing, 29(4), 840–851. Human Papillomavirus and HIV Infection Davies, J. E. (2000). Hide and seek. Make sure HPV infection doesn’t escape diagnosis. Advance for Nurse Practitioners, 8(9), 39–43. Dell, D., Chen, H., Ahmad, F., & Stewart, D. (2000). Knowledge about human papillomavirus among adolescents. Obstetrics & Gynecology, 96 (5, Part 1), 653–656. French, L., Nashelsky, J., & White D. (2002). What is the most effective treatment for external genital warts? Journal of Family Practice, 51(4), 313. Hader, S. L., Smith, D. K., Moore, J. S., & Holmberg, S. D. (2001). HIV infection in the United States: Status at the millennium. Journal of the American Medical Association, 285(9), 1186–1192. Mosicki, A. B., Hills, N., Shiboski, S., et al. (2001). Risks for incident human papillomavirus infection and low-grade squamous intraepithelial lesion development in young females. Journal of the American Medical Association, 285(23), 2995–3002. Naomi, J., & Moscicki, A. (2000). Human papillomavirus infections in women with HIV disease: Prevalence, risk and management. The AIDS Reader, 10(11), 659–668. Hysterectomy Broder, M., Kanouse, D., Mittman, B., & Bernstein, S. (2000). The appropriateness of recommendations for hysterectomy. Obstetrics & Gynecology, 95(2), 199–204. Brooks-Brunn, J. (2000). Risk factors associated with postoperative pulmonary complications following total abdominal hysterectomy. Clinical Nursing Research, 9(1), 27–46. Kjerulff, K., Langenberg, P., Rhodes, J., et al. (2000). Effectiveness of hysterectomy. Obstetrics & Gynecology, 95(3), 319–326. Lewis, C., Groff, J., Herman, C., et al. (2000). Overview of women’s decision making regarding elective hysterectomy, oophorectomy and hormone replacement therapy. Journal of Women’s Health and Gender-Based Medicine, 9(Suppl 2), 5–14. Moreira, V. (2000). Learning curve: Hysterectomy, nursing the physical and emotional wounds. Nursing Times, 96(20), 41–42. *Wade, J., Pletsch, P., Morgan, S., & Menting, S. (2000). Hysterectomy: What do women need and want to know? JOGNN, 29(1), 33–42. Winston, K. (2000). Reflections on women’s health. In my shoes: a story about hysterectomy. AWHONN Lifelines, 4(2), 64 –66. Pelvic Inflammatory Disease (PID) *Champion, J. D., Piper, J. N., Shain, R. N., et al. (2001). Minority women with sexually transmitted diseases: Sexual abuse and risk for pelvic inflammatory disease. Research in Nursing & Health, 24(1), 38–43. Molitor, L. (2001). A 26-year-old woman with right shoulder pain. Journal of Emergency Nursing, 27(4), 404–405. Ness, R. B., Soper, D. E., Holley, R. L., et al. (2001a). Douching and endometritis: Results from the PID evaluation and clinical health (PEACH) study. Sexually Transmitted Diseases, 28(4), 240–245. Ness, R. B., Soper, D. E., Holley, R. L., et al. (2001b). Hormonal and barrier contraception and risk of upper genital tract disease in the PID Evaluation and Clinical Health (PEACH) study. American Journal of Obstetrics & Gynecology, 185(1), 121–127. Ness, R. B., Soper, D. E., Holley, R. L., et al. (2001c). Effectiveness of inpatient and outpatient treatment strategies for women with pelvic inflammatory disease: Results from the Pelvic Inflammatory Disease Evaluation and Clinical Health (PEACH) Randomized Trial. American Journal of Obstetrics & Gynecology. 186(5), 929–937.
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Peipert, J. F., Ness, R. B., Blume, J., et al. (2001). Clinical predictors of endometritis in women with symptoms and signs of pelvic inflammatory disease. American Journal of Obstetrics & Gynecology, 184(5), 856–863. Ross, J. (2001). Pelvic inflammatory disease. British Medical Journal, 322(7287), 658–659. Reproductive Malignancy American College of Obstetricians and Gynecologists. (2001). ACOG committee opinion: Tamoxifen and endometrial cancer. International Journal of Gynaecology & Obstetrics. 73(1), 77–79. American College of Obstetricians and Gynecologists. (2000). ACOG committee opinion: Breast-ovarian cancer screening. International Journal of Gynaecology & Obstetrics. 75(3), 339–340. Cottreau, C., Ness, R., & Kriska, A. (2000). Physical activity and reduced risk of ovarian cancer. Obstetrics & Gynecology,96(4), 609–614. Furniss, K. (2000). Tomatoes, Pap smears and tea? Adopting behaviors that may prevent reproductive cancers and improve health. JOGNN, 29(6), 641–652. Lammers, S., Schaefer, K., Ladd, E., & Echenberg, R. (2000). Caring for women living with ovarian cancer: Recommendations for advanced practice nurses. JOGNN, 29(6), 567–573. Lowdermilk, D., & Germino, B. (2000). Helping women and their families cope with the impact of gynecologic cancer. JOGNN, 29(6), 653–660. Marchbanks, P., Hoyt, W., Bastos, E., et al. (2000). Cigarette smoking and epithelial ovarian cancer by histologic type. Obstetrics & Gynecology, 95(2), 255–260. Massad, L., Abu-Rustum, N., Lee, S., & Renta, V. (2000). Poor compliance with postmolar surveillance and treatment protocols by indigent women. Obstetrics and Gynecology, 96(6), 940–944. Montz, F. (2000). Management of high-grade cervical intraepithelial neoplasia and low-grade squamous intraepithelial lesion and potential complications. Clinical Obstetrics & Gynecology, 43(2), 394–409. National Institutes of Health (NIH) (1996). NIH consensus statement: Cervical cancer. 14(1), 1–38. Olopade, O., & Cummings, S. (2000). Breast and ovarian cancer: Counseling patients about risk. Consultant, 40(11), 1930–1940. Santoso, J., Canada, T., Latson, B., et al. (2000). Prognostic nutritional index in relation to hospital stay in women with gynecologic cancer. Obstetrics and Gynecology, 95(6 Pt 1), 844–846. Toxic Shock Syndrome Hajjeh, R., Reingold, A., Weil, A., et al., (1999). Toxic shock syndrome in the United States: Surveillance update, 1979–1996. Emerging Infectious Diseases, 5(6), 807–810. Nakase, J. (2000). Update on emerging infections from the Centers for Disease Control and Prevention. Annals of Emergency Medicine, 36(3), 269–270. Vaginitis and Vulvovaginal Infections Cullins, V., Dominguez, L., Guberski, T., et al. (1999). Treating vaginitis. Nursing Practice, 24(10), 46–50. Harmanli, O., Cheng, G., Nyirjesy, P., et al. (2000). Urinary tract infections in women with bacterial vaginosis. Obstetrics & Gynecology, 95(5), 710–712. Hutti, M., & Hoffman, C. (2000). Pearls for practice: Cytolytic vaginosis: An overlooked cause of cyclic vaginal itching and burning. Journal of the American Academy of Nursing Practice, 12(2), 55–57. *Lowe, N., & Ryan-Wenger, N. (2000). A clinical test of women’s selfdiagnosis of genitourinary infections. Clinical Nursing Research, 9(2), 144–160. Paavonen, J., Mangioni, C., Martin, M., & Wajszcuk, C. (2000). Vaginal clindamycin and oral metronidazole for bacterial vaginosis: A randomized trial. Obstetrics & Gynecology, 96(2), 256–260. Sobel, J. (2000). Managing vulvovaginal candidiasis. Female Patient, 5(5), 20–23. Witkin, S., & Giraldo, P. (2000). The quandary of recurrent vaginal candidiasis. Patient Care, 34(2), 123–126.
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RESOURCES AND WEBSITES American Cancer Society, 1599 Clifton Road NE, Atlanta, GA 30329; (800) ACS-2345; http://www.cancer.org. American Social Health Association, P.O. Box 13827, Research Triangle Park, NC 27709; (800) 227-8922; http://www.ashastd.org/ std/std.html; teen website: http://www.iwannaknow.org. Association of Reproductive Health Professionals, 2401 Pennsylvania Avenue, Suite 350, Washington, DC 20037-1718; (202) 466-3825; http://www.arhp.org. AWHONN: Association of Women’s Health, Obstetrical and Neonatal Nurses, 2000 L St., NW, Suite 7400, Washington, DC 20036; http://www.awhonn.org. Cancer Journey: Issues for Survivors. A leader’s guide and videotape available from the National Cancer Institute (1-800-4-CANCER) Centers for Disease Control and Prevention, Office of Women’s Health, 1600 Clifton Road, MS: D-51, Atlanta, GA 30033; (404) 639-7230; http://www.cdc.gov/od/owh/whstd.htm.
Endometriosis Association, 8585 N. 76th Place, Milwaukee, WI 53223; (800) 992-3636; http://www.endometriosisassn.org. Gay and Lesbian Medical Association, 459 Fulton St., Suite 107, San Francisco, CA 94102; (415) 225-4547; http://www.glma.org/ home.html. Herpes Hotline: (919) 361-8488. Herpetics Engaged in Living Productively (HELP), 260 Sheridan Avenue, Palo Alto, CA 94306. Medscape: http://www.medscape.com (go to Women’s Health). National AIDS Hotline: (800) 342-AIDS; http://www.ashastd.org/nah. National Institutes of Health: http://www.Clinicaltrials.gov. National STD Hotline: (800) 227-8922 or (800) 342-2437; http://www. ashastd.org/nah. Planned Parenthood Federation of America, 810 Seventh Avenue, New York, NY 10019; (800) 829-PPFA; http://www.plannedparenthood. org/sti/. Resolve: The National Infertility Association, 1310 Broadway, Somerville, MA 02144; (888) 623-0744; http://www.resolve.org.
Chapter
48 ●
Assessment and Management of Patients With Breast Disorders
LEARNING OBJECTIVES
●
On completion of this chapter, the learner will be able to: 1. Develop a teaching plan for breast self-examination for patients 2. 3. 4. 5.
and consumer groups. Describe the diagnostic tests used to detect breast disorders. Use the nursing process as a framework for care of the patient with breast cancer. Compare the therapeutic effectiveness of chemotherapy, surgery, and radiation therapy in treating breast cancer. Describe the physical, psychosocial, and rehabilitative needs of the patient who has had breast surgery for the treatment of breast cancer.
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n many cultures, the breast plays a significant role in a woman’s sexuality and identification of herself as female. Although advances in the diagnosis and treatment of breast disorders are changing the prognosis for breast disease and cancer, women’s responses to possible breast disease include fear of disfigurement and loss of sexual attractiveness and fear of death. The woman with breast disease may undergo diagnostic testing, surgery, radiation therapy, chemotherapy, and hormonal therapy. Thus, nurses caring for patients with breast disease must have an in-depth understanding of these treatment modalities and expert assessment and clinical skills to address the physical and psychological needs of patients facing breast disorders, and their families.
Anatomic and Physiologic Overview In males and females, the breasts are the same until puberty, when estrogen and other hormones initiate breast development in females. This development usually occurs at about age 10 years and continues until about age 16 years, although the range can vary
from 9 to 18 years. Stages of breast development are described as Tanner stages 1 through 5. Stage 1 describes a prepubertal breast. Stage 2 is breast budding, the first sign of puberty in a female. Stage 3 involves further enlargement of breast tissue and the areola (a darker tissue ring around the nipple), and stage 4 occurs when the nipple and areola form a secondary mound on top of the breast tissue. Stage 5 is the continued development of a larger breast with a single contour. The breast contains glandular (parenchyma) and ductal tissue, along with fibrous tissue that binds the lobes together and fatty tissue in and between the lobes. These paired mammary glands are located between the second and sixth ribs over the pectoralis major muscle from the sternum to the midaxillary line. An area of breast tissue, called the tail of Spence, extends into the axilla. Cooper’s ligaments, which are fascial bands, support the breast on the chest wall. Figure 48-1 shows the anatomy of the fully developed breast. Each breast consists of 12 to 20 cone-shaped lobes that are made up of lobules containing clusters of acini, small structures ending in a duct. All of the ducts in each lobule empty into an
Glossary atypical hyperplasia: abnormal increase in the number of cells in a specific area within the ductal or lobular areas of the breast; this abnormal proliferation increases the risk for cancer benign proliferative breast disease: various types of atypical, yet noncancerous, breast tissue that increase the risk for breast cancer BRCA-1: gene on chromosome 17 that, when damaged or mutated, places a woman at greater risk for breast or ovarian cancer, or both, compared with women who do not have the mutation BRCA-2: gene on chromosome 17 that, when damaged or mutated, places a woman at greater risk for breast cancer (though less so than BRCA-1) compared with women who do not have the mutation breast-conservation therapy: surgery to remove a breast tumor and a margin of tissue around the tumor without removing any other part of the breast; may include an axillary lymph node dissection, radiation therapy, or both breast self-examination (BSE): technique for checking one’s own breasts for lumps or suspicious changes ductal carcinoma in situ (DCIS): cancer cells that start in the ductal system of the breast but have not penetrated the surrounding tissue estrogen and progesterone receptor assay: test to determine whether the breast tumor is nourished by hormones; this information is useful in making a prognosis and determining treatment fibrocystic breast changes: term used to describe certain benign changes in the breast, typically associated with palpable nodularity, lumpiness, swelling, or pain
fine-needle aspiration (FNA): the removal of fluid for diagnostic analysis from a cyst or cells from a mass using a needle and syringe galactography: use of mammography after an injection of radiopaque dye to diagnose problems in the ductal system of the breast gynecomastia: overdeveloped breast tissue typically seen in adolescent boys lobular carcinoma in situ (LCIS): an atypical change and proliferation of the lobular cells of the breast; previously considered a premalignant condition but now considered a marker of increased risk for invasive breast cancer lymphatic mapping and sentinel node biopsy: procedure using radiopaque dye and nuclear medicine techniques to identify and analyze the first draining lymph node from the breast within the axillary region lymphedema: chronic swelling of an extremity due to interrupted lymphatic circulation, typically from an axillary dissection mammography: an x-ray of the breast; the principal method of screening for and detection of breast cancer in women mammoplasty: surgical procedure to reconstruct or change the size or shape of the breast; can be done for reduction or augmentation mastalgia: breast pain, usually related to hormonal fluctuations or irritation of a nerve mastitis: inflammation or infection of the breast medullary carcinoma: special type of infiltrating breast cancer in which the tumor is well defined, with obvious boundaries modified radical mastectomy: removal of the breast tissue, nipple–areola complex,
and a portion of the axillary lymph nodes Paget’s disease: form of breast cancer that begins in the ductal system and involves the nipple, areola, and surrounding skin prophylactic mastectomy: removal of the breast to reduce the risk for or to prevent the development of breast cancer in women considered at high risk stereotactic biopsy: computer-guided method of core needle biopsy that is useful when masses in the breast cannot be felt but can be visualized using mammography surgical biopsy: procedure in which tissue samples or the entire specimen is removed for examination under a microscope by a pathologist tissue expander with permanent implant: series of surgical procedures used to reconstruct the breast after a mastectomy; involves stretching the skin and muscle before inserting the permanent implant total mastectomy: removal of the breast tissue and nipple–areola complex, typically used as one type of treatment for DCIS transverse rectus abdominis myocutaneous flap (TRAM flap): method of breast reconstruction in which adipose tissue and muscle from the lower abdomen, along with their circulatory structures, are transferred to the mastectomy site ultrasonography: imaging method using high-frequency sound waves to diagnose whether masses are solid or fluid-filled wire needle localization: procedure used to perform a breast biopsy when the lump is difficult to palpate but can be visualized using mammography; a wire is inserted into the breast tissue under mammographic visualization, and the surgeon then removes the tissue surrounding the wire
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Pectoralis major muscle Intercostal muscles
Alveolus Ductule Duct Axillary tail of Spence
Lactiferous duct Lactiferous sinus Upper outer quadrant
Nipple pore
Lower outer quadrant
Suspensory ligaments of Cooper
A
Lateral view
Upper inner quadrant
Lower inner quadrant
B
FIGURE 48-1
(A) Anatomy of the breast. (B) Areas of breast, including the tail of Spence. Adapted from Weber, J., & Kelley, J. (1998). Health assessment in nursing (2nd ed). Philadelphia: Lippincott Williams & Wilkins.
ampulla, which then opens onto the nipple after narrowing. About 85% of the breast is fat.
Assessment HEALTH HISTORY AND CLINICAL MANIFESTATIONS When assessing a patient who describes a breast problem, the nurse should ask the woman when she noted the problem and how long it has been present. Other questions include: Is pain associated with the symptom, and can you feel any areas in your breast that are of concern? What are your breast self-examination (BSE) practices? Have you had a mammogram or any other screening or diagnostic tests? If so, when? What follow-up recommendations were made? The woman is asked about her reproductive history because of its relationship to risk for breast disorders. Questions should include the woman’s age at menarche, last menstrual period, cycle regularity, and use of oral contraceptives or other hormone products. Other necessary information includes her history of pregnancies, live births, abortions, or miscarriages, and breastfeeding. If the patient is postmenopausal, her age at menopause and any symptoms she experienced and current or previous use of hormone replacement therapy are also addressed. General health assessment includes the patient’s use of tobacco and alcohol. Her medical and surgical history is important to obtain, along with any family history of diseases, particularly cancer. Social information, such as marital status, occupation, and the availability of resources and support persons, should also be elicited.
Psychosocial Implications of Breast Disease Because of the significant role of the breast in a woman’s sexuality, responses to any actual or suspected disease may include fear, anxiety, and depression. Specific responses may include fears of disfigurement, loss of sexual attractiveness, abandonment by her partner, and death. These fears may cause some women to delay seeking health care for evaluation of a possible breast problem. Alternatively, in some women anxiety or fear regarding breast cancer may cause them to seek the services of a health care provider for the slightest change or problem. In response to these reactions, the nurse’s role is to identify the patient’s concerns, anxieties, and fears. Patient education and psychosocial support become key nursing interventions. Assessment of the woman’s concerns related to breast care and her responses to a potential problem is important whether the problem is benign or potentially malignant. Nurses can help women through the potentially frightening visit to the primary health care provider or surgeon. Because of underlying fears about a breast problem, anxiety management is a valuable intervention, and the nurse’s calm, caring demeanor, along with astute listening skills and concrete direction and guidance, can decrease a woman’s anxiety during the process.
PHYSICAL ASSESSMENT: FEMALE BREAST Examination of the female breast can be conducted during any general physical or gynecologic examination or whenever the patient suspects, reports, or fears breast disease. A clinical breast examination is recommended at least every 3 years for women ages
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NURSING RESEARCH PROFILE 48-1
Undergoing Diagnosis for Breast Disease Poole, K., & Lyne, P. A. (2000). The ‘cues’ to diagnosis: Describing the monitoring activities of women undergoing diagnostic investigations for breast disease. Journal of Advanced Nursing, 31(4), 752–758.
Purpose Women undergoing diagnostic workup for symptoms of breast disease have identified the process as very stressful for them and their partners. This qualitative portion of a larger study investigated the experience of undergoing fine-needle biopsy and waiting for the results of the biopsy. The transactional theory of stress, appraisal, and coping of Lazarus and Folkman served as the framework for the study. Study Sample and Design Focus interviews were conducted with a subset of the 235 women who participated in the larger study and had fine-needle aspirations at two outpatient breast clinics. The subset consisted of 40 women; 20 of the women were diagnosed with breast cancer and 20 with benign breast disease. The women were interviewed in their homes 2 to 3 weeks post-diagnosis about their experiences from discovery of their breast abnormality to the time of diagnosis. The interviews, which ranged from 30 to 90 minutes, were audiotaped. Categories of themes emerging from the interviews were generated: the discovery of the breast abnormality and women’s reflections after receiving biopsy results. Findings Analysis of the transcripts revealed four different types of threatrelated cues during the diagnostic period: temporal, interpersonal, procedural, and spatial. Temporal cues identified by women in the study were those related to time. For example, the amount of time from referral by the primary care practitioner to the specialist breast unit was perceived by women as an indicator of the urgency of their
20 to 40 years, and then annually. A thorough breast examination, including instruction in BSE, takes at least 10 minutes.
problem; the quicker the referral, the greater urgency they perceived their problem to have. Interpersonal cues identified by the women were words, actions, gestures, or pauses in conversation by health care personnel. Active identification and interpretation of interpersonal cues by women were linked to uncertainty and lack of control during the diagnostic process. Procedural cues were those associated with the aspects of how the biopsy and other diagnostic procedures were performed. For example, the need to repeat an x-ray or the refusal of the radiologist to let the patient see the mammogram were taken as cues of a likely diagnosis of cancer. Spatial cues were those in which women interpreted usually uneventful aspects in the environment as indicative of their diagnosis. For example, one women interpreted the actions of health care personnel in arranging the chairs in the room in a certain way as she entered as indicative of the fact that they were about to inform her of a diagnosis of cancer. Nursing Implications These findings, described by the researchers as monitoring activities on the part of women undergoing diagnostic assessment for breast cancer, suggest the need women have to know their diagnosis and to reduce their uncertainty about the diagnosis. The stress associated with misinterpretation of these cues suggests the need for nurses and other health care providers to provide women with accurate and timely information to minimize their possible misinterpretation of behaviors. Nurses can help patients understand what time frames exist within the institution and explain the routines involved with the process of undergoing evaluation for a breast lump.
may suggest a potential malignancy. The clavicular and axillary regions are inspected for swelling, discoloration, lesions, or enlarged lymph nodes.
Inspection Examination begins with inspection. The patient disrobes to the waist and sits in a comfortable position facing the examiner. The breasts are inspected for size and symmetry. A slight variation in the size of each breast is common and generally normal. The skin is inspected for color, venous pattern, and thickening or edema. Erythema (redness) may indicate benign local inflammation or superficial lymphatic invasion by a neoplasm. A prominent venous pattern can signal increased blood supply required by a tumor. Edema and pitting of the skin may result from a neoplasm blocking lymphatic drainage and giving the skin an orangepeel appearance (peau d’orange), a classic sign of advanced breast cancer. Examples of abnormal breast findings can be found in Chart 48-1. Although the appearance of the nipple–areola complex varies greatly between patients, for individual women the two are generally similar in size and shape. Inversion of one or both is not uncommon and is a significant finding only when of recent origin. Ulceration, rashes, or spontaneous nipple discharge requires evaluation. To elicit a dimpling or retraction that may otherwise go undetected, the examiner instructs the patient to raise both arms overhead. This maneuver normally elevates both breasts equally. Next, the patient is instructed to place her hands at her waist and push in. These movements, causing contraction of the pectoral muscles, do not normally alter the breast contour or nipple direction. Any dimpling or retraction during these position changes
Palpation Palpation of the axillary and clavicular areas is easily performed with the patient seated. To examine the axillary lymph nodes, the examiner gently abducts the patient’s arm from the thorax. The patient’s left forearm is grasped gently and supported with the examiner’s left hand. The right hand is then free to palpate the axillae and note any lymph nodes that may be lying against the thoracic wall. The flat parts of the fingertips are used to gently palpate the areas of the central, lateral, subscapular, and pectoral nodes (Fig. 48-2). Normally, these lymph nodes are not palpable, but if they are enlarged, their size, location, mobility, consistency, and tenderness are noted. The breasts are also palpated with the patient sitting in an upright position. The patient is then assisted to a supine position. Before the breast is palpated, the patient’s shoulder is elevated by a small pillow to balance the breast on the chest wall. Failure to do this allows the breast tissue to slip laterally, and a breast mass may be missed in this thickened tissue. Light, systematic palpation includes the entire surface of the breast and the axillary tail. The examiner may choose to proceed in a clockwise direction, following imaginary concentric circles from the outer limits of the breast toward the nipple. Other acceptable methods are to palpate from each number on the face of the clock toward the nipple in a clockwise fashion or along imaginary vertical lines on the breast (Fig. 48-3).
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Chart 48-1
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• ASSESSMENT
Abnormal Breast Findings Retraction Signs • Signs include skin dimpling, creasing, or changes in the contour of the breast or nipple • Secondary to fibrosis or scar tissue formation in the breast • Retraction signs may appear only with position changes or with breast palpation.
Dimpling
Increased Venous Prominence • Associated with breast cancer if unilateral • Unilateral localized increase in venous pattern associated with malignant tumors • Normal with breast enlargement associated with pregnancy and lactation if bilateral and bilateral symmetry Increased venous prominence
Flattening of nipple
Retraction signs
Retraction with compression
Breast Cancer Mass (Malignant Tumor) • Usually occurs as a single mass (lump) in one breast • Usually nontender • Irregular shape • Firm, hard, embedded in surrounding tissue • Referral and biopsy indicated for definitive diagnosis
Peau d’orange
Breast cancer mass
Breast Cyst (Benign Mass of Fibrocystic Disease) • Occur as single or multiple lumps in one or both breasts • Usually tender (omitting caffeine reduces tenderness); tenderness increases during premenstrual period • Round shape • Soft or firm, mobile • Referral and biopsy indicated for definitive diagnosis, especially for first mass; later masses may be evaluated over time by a specialist Fibroadenoma (Benign Breast Lump) • Usually occurs as a single mass in women aged 15–35 years • Usually nontender • May be round or lobular • Firm, mobile, and not fixed to breast tissue or chest wall • No premenstrual changes • Referral and biopsy indicated for definitive diagnosis
Peau d’Orange (Edema) • Associated with breast cancer • Caused by interference with lymphatic drainage • Breast skin has orange peel appearance • Skin pores enlarge • May be noted on the areola • Skin becomes thick, hard, immobile • Skin discoloration may occur
Nipple Inversion • Considered normal if long-standing • Associated with fibrosis and malignancy if recent development
Nipple inversion
Breast cysts
Acute Mastitis (Inflammation of the Breasts) • Associated with lactation but may occur at any age • Nipple cracks or abrasions noted • Breast skin reddened and warm to touch • Tenderness • Systemic signs include fever and increased pulse Paget’s Disease (Malignancy of Mammary Ducts) • Early signs: erythema of nipple and areola • Late signs: thickening, scaling, and erosion of the nipple and areola
Fibroadenoma
Paget’s disease
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Supraclavicular
Clavicle
Lateral Subclavicular Central axillary Subscapular
monly found in menstruating women and are usually well defined and freely movable. Premenstrually, cysts may be larger and more tender. Malignant tumors, on the other hand, tend to be hard, the consistency of a pencil eraser, poorly defined, fixed to the skin or underlying tissue, and usually nontender. A physician should evaluate any abnormalities detected during inspection and palpation.
PHYSICAL ASSESSMENT: MALE BREAST
FIGURE 48-2
Palpating axillary nodes in breast examination.
During palpation, the examiner notes tissue consistency, patient-reported tenderness, or masses. If a mass is detected, it is described by its location (eg, left breast, 2 cm from the nipple at 2 o’clock position). Size, shape, consistency, border delineation, and mobility are included in the description. Finally, the areola is gently compressed to detect any discharge or secretion. The breast tissue of the adolescent is usually firm and lobular, whereas that of the postmenopausal woman is more likely to feel thinner and more granular. During pregnancy and lactation, the breasts are firmer and larger, with lobules that are more distinct. Hormonal changes cause the areola to darken. Cysts are com-
Circular
Wedge
Vertical strip
FIGURE 48-3 Breast examination with the woman in a supine position (above). The entire surface of the breast is palpated from the outer edge of the breast to the nipple. Alternative palpation patterns are circular or clockwise, wedge, and vertical strip (below). From Weber, J. & Kelley, J. (2003). Health assessment in nursing (2nd ed.). Philadelphia: Lippincott Williams & Wilkins.
Because breast cancer can occur in men, examination of the male breast and axillae is an important part of physical assessment. The nipple and areola are inspected for masses. Most cancers in men are found at a later stage, possibly because men are not aware of their risk for developing breast cancer. Treatment of breast cancer in males is similar as well. Gynecomastia (overdeveloped mammary glands in the male) is differentiated from the soft, fatty enlargement of obesity by the firm enlargement of glandular tissue beneath and immediately surrounding the areola. The same procedure for palpating the female axillae is used when assessing the male axillae.
Diagnostic Evaluation BREAST SELF-EXAMINATION BSE instruction can be performed during assessment as part of the physical examination; it can be taught in any setting, either to individuals or groups. Instructions about BSE are provided to men if they have a family history of breast cancer because these men may be at higher risk for male breast cancer. Variations in breast tissue occur during the menstrual cycle, pregnancy, and menopause. Therefore, normal changes must be distinguished from those that may signal disease. Most women notice increased tenderness and lumpiness before their menstrual period; therefore, BSE is best performed after menses (day 5 to day 7, counting the first day of menses as day 1), when less fluid is retained. Also, many women have grainy-textured breast tissue, but these areas are usually less nodular after menses. Because women themselves detect many breast cancers, priority is given to teaching all women how and when to examine their breasts (Chart 48-2). It is estimated that only 25% to 30% of women perform BSE proficiently and regularly each month. Younger women, who have normal lumps in their breasts, find it particularly difficult to perform BSE because they have a harder time distinguishing normal from abnormal lumps and are not sure of what they are feeling due to the density of their breast tissue. Even women who perform BSE may delay seeking medical attention because of fear, economic factors, lack of education, reluctance to act if no pain is involved, psychological factors, and modesty. Women should begin practicing BSE at the time of their first gynecologic examination, which usually occurs in their late teens or early 20s. All health care providers, aware of these implications, should encourage women to examine their own breasts and teach them to recognize early changes that may indicate problems. The nurse plays a pivotal role in preventive education. Almost all settings lend themselves to teaching, providing information, and encouraging appropriate care for prevention, detection, and treatment of breast problems. An individual teaching session with the patient can increase the frequency with which she practices BSE. A lesson in BSE should include the following: optimal timing for BSE (5 to 7 days after menses begin for premenopausal women
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and once monthly for postmenopausal women), a demonstration of examination techniques, a review of what normal breast tissue feels like, a discussion on identification of breast changes, and a return demonstration on the patient and a breast model. Patients who have had breast surgery for the treatment of breast cancer are carefully instructed to examine themselves for any nodules or changes in their breasts or along the chest wall that may indicate a recurrence of the disease. Films or videos about BSE, shower cards, and pamphlets can be obtained from local chapters of the American Cancer Society. The National Cancer Institute in Bethesda, Maryland, offers a program that teaches nurses to instruct patients in BSE and also provides teaching aids. The National Alliance for Breast Cancer Organizations, a clearinghouse for lay materials on breast cancer education, is another resource.
MAMMOGRAPHY Mammography is a breast-imaging technique that can detect nonpalpable lesions and assist in diagnosing palpable masses. The procedure takes about 20 minutes and can be performed in an xray department or independent imaging center. Two views are taken of each breast: a craniocaudal view and a mediolateral oblique view. For these views, the breast is mechanically compressed from top to bottom and side to side (Fig. 48-4). Women may experience some fleeting discomfort because maximum compression is necessary for proper visualization. The current mammograms are compared with previous mammograms, and any changes indicate a need for further investigation. Mammography may detect a breast tumor before it is clinically palpable (ie, smaller than 1 cm); however, it has limitations and is not foolproof. The false-negative rate ranges between 5% and 10%; it is generally greater in younger women with greater density of breast tissue. Some patients have very dense breast tissue, making it difficult to detect lesions with mammography. Patients scheduled for a mammogram may voice concern about exposure to radiation. The radiation exposure is equivalent to about 1 hour of exposure to sunlight, so patients would have
X-ray tube
to have many mammograms in a year to increase their cancer risk. The benefits of this test outweigh the risks. Because the quality of mammography varies widely from one setting to the next, it is important for women to find accredited breast care centers that produce reliable mammograms. Current mammographic screening guidelines from the American Cancer Society recommend a mammogram every year starting at the age of 40 years. A baseline mammogram should be obtained after the age of 35 years and by the age of 40. Younger women who are identified as at a higher risk for breast cancer by family history should seek the opinion of a breast specialist about when to begin screening mammograms. Several studies suggest that screening for high-risk women should begin about 10 years before the age of diagnosis of the family member with breast cancer (Hartmann, Sellers, Schaid et al., 1999). In families with a history of breast cancer, a downward shift in age of diagnosis of about 10 years is seen (eg, grandmother diagnosed with breast cancer at age 48, mother diagnosed with breast cancer at age 38, then daughter should begin screening at age 28). Nurses need to provide teaching about screening guidelines for women in the general population and those at high risk so that these women can make informed choices about screening. The combination of screening mammography, physical examination, and BSE has reduced overall mortality from breast cancer by 63% among women ages 40 to 69 years (Tabar, Vitak, Tony et al., 2001). Despite the decreased mortality associated with mammographic screening, it has not been used equitably across the U.S. population. Current statistics indicate that 67% of women 40 years of age and over have had a mammogram within the past 2 years (CDC Database, 2000). Women with fewer resources (eg, elderly, poor, minority women, women without health insurance) often do not have the means to undergo mammography or the resources for follow-up treatment when lesions are detected. Recent studies have shown that social support contributes to adherence to mammographic screening guidelines (Anderson, Urban & Etzioni, 1999; Faccione, 1999; Lauver, Kane, Bodden et al., 1999). Many nurses direct their efforts at educating women about the benefits of mammography. Working to overcome barriers to screening mammography, especially among the elderly and women with disabilities, is an important nursing intervention in the community, and nurses have an important role in the development of educational materials targeted to specific literacy levels and ethnic groups.
Galactography Galactography is a mammographic diagnostic procedure that involves injection of less than 1 mL of radiopaque material through a cannula inserted into a ductal opening on the areola, followed by a mammogram. It is performed when the patient has a bloody nipple discharge on expression, spontaneous nipple discharge, or a solitary dilated duct noted on mammography. These symptoms may indicate a benign lesion or a cancerous one.
X-ray
Compression paddle
ULTRASONOGRAPHY
X-ray film cassette
A
FIGURE 48-4
B
The mammography procedure (A) relies on x-ray imaging to produce the mammogram (B), which in this case reveals a breast lump.
Ultrasonography (ultrasound) is used in conjunction with mammography to distinguish fluid-filled cysts from other lesions. A transducer is used to transmit high-frequency sound waves through the skin and into the breast, and an echo signal is measured. The echo waves are interpreted electronically and then displayed on a screen. This technique is 95% to 99% accurate in diagnosing cysts but does not definitively rule out a malignant lesion.
Chapter 48
Assessment and Management of Patients With Breast Disorders
For women with dense breasts, the introduction of screening ultrasound examinations has been researched during this past decade. The addition of ultrasonography to breast cancer screening can increase the sensitivity of screening for this population of women, who tend to be either young or on hormone replacement therapy. The largest study showed an increase in cancer detection by 17% with the addition of screening ultrasonography (Kolb, Lichy & Newhouse, 1998). Further research will help provide information on the usefulness of ultrasound as a screening modality.
MAGNETIC RESONANCE IMAGING Magnetic resonance imaging (MRI) of the breast is a promising tool for use in diagnosing breast conditions. It is a highly sensitive, although not specific, test and serves as an adjunct to mammography. A coil is placed around the breast, and the patient is placed inside the MRI machine for about 2 minutes. An injection of gadolinium, a contrast dye, is given intravenously. MRI of the breast can be helpful in determining the exact size of a lesion or the presence of multiple foci more precisely than mammography. It also can determine more precisely than a CT scan if a lesion is fixed to the chest wall. Other uses include identifying occult (undetectable) breast cancer, determining the tumor’s response to chemotherapy, and determining the integrity of saline or silicone breast implants. The cost of breast MRI, however, is high; therefore, it is not currently used for routine screening. However, the sensitivity of the MRI may be beneficial for cancer detection in higher-risk women, and the results from preliminary studies are encouraging (Schnall, 2001).
PROCEDURES FOR TISSUE ANALYSIS Fine-Needle Aspiration Fine-needle aspiration (FNA) is an outpatient procedure usually initiated when mammography, ultrasonography, or palpation detects a lesion. A surgeon performs the procedure when there is a palpable lesion, or a radiologist performs it under x-ray guidance for nonpalpable lesions. Injection of a local anesthetic may or may not be used, but most times the surgeon or radiologist inserts a 21- or 22-gauge needle attached to a syringe into the site to be sampled. The syringe is then used to withdraw tissue or fluid into the needle. This cytologic material is spread on a slide and sent to the laboratory for analysis. FNA is less expensive than other diagnostic methods, and results are usually available quickly; however, this diagnostic test is often not 100% accurate, and the false-negative rate is substantial. False-negative or false-positive results are possible, and clinical follow-up depends on the level of suspicion about the breast lesion.
Stereotactic Biopsy Stereotactic biopsy, also an outpatient procedure, is performed for nonpalpable lesions found on mammography. The patient lies prone on a special table, and the breast is positioned through an opening in the table and compressed for a mammogram. The lesion to be sampled is then located with the aid of a computer. Next, a local anesthetic is injected into the entry site on the breast, a core needle is inserted, and samples of the tissue are taken for pathologic examination. If the lesion is small, a clip is placed at the site of the biopsy, so that a specific area can be visualized again as another mammogram is performed. This technique allows ac-
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curate diagnosis and often allows the patient to avoid a surgical biopsy, although some patients may end up needing a surgical biopsy, depending on the pathologic diagnosis.
Surgical Biopsy Surgical biopsy is the most common outpatient surgical procedure. Eight of 10 lesions are benign on biopsy. The procedure is usually done using local anesthesia, moderate sedation, or both. The biopsy involves excising the lesion and sending it to the laboratory for pathologic examination. EXCISIONAL BIOPSY Excisional biopsy is the usual procedure for any palpable breast mass. The entire lesion, plus a margin of surrounding tissue, is removed. This type of biopsy may also be referred to as a lumpectomy. Depending on the clinical situation, a frozen section may be done at the time of the biopsy (a small piece of the mass or lesion is given a provisional diagnosis by the pathologist), so that the surgeon can provide the patient with a diagnosis in the recovery room. INCISIONAL BIOPSY Incisional biopsy is performed when tissue sampling alone is required; this is done both to confirm a diagnosis and to determine the hormonal receptor status. Complete excision of the area may not be possible or immediately beneficial to the patient, depending on the clinical situation. This procedure is often performed in women with locally advanced breast cancer or in cancer patients with a suspicion of recurrent disease, whose treatment may depend on the tumor’s estrogen and progesterone receptor status. These receptors are identified during pathologic examination of the tissue. TRU-CUT CORE BIOPSY In a Tru-Cut core biopsy, the surgeon uses a special large-lumen needle to remove a core of tissue. This procedure is used when a tumor is relatively large and close to the skin surface and the surgeon strongly suspects that the lesion is a carcinoma. If cancer is diagnosed, the tissue is also tested for hormone receptor status. WIRE NEEDLE LOCALIZATION Wire needle localization is a technique used when mammography detects minute, pinpoint calcifications (indicating a potential malignancy) or nonpalpable lesions and a biopsy is necessary. A long, thin wire is inserted, usually painlessly, through a needle before the excisional biopsy under mammographic guidance to ensure that the wire tip designates the area to undergo biopsy. The wire remains in place after the needle is withdrawn to ensure a precise biopsy. The patient is then taken to the operating room, where the surgeon follows the wire down and excises the area around the wire tip. The tissue removed is x-rayed at the time of the procedure; these specimen x-rays, along with follow-up mammograms taken several weeks later (after the site has healed), verify that the area of concern was located and removed.
Nursing Care of the Patient Undergoing a Breast Biopsy Breast biopsies are one of the most common ambulatory surgical procedures performed, with 80% of the results negative for malignancy (Norris, 2001). Prior to the procedure, the nurse’s
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role is to provide instruction; however, it is important for the nurse to first assess how the woman is coping with her need for the procedure and her ability to process information about the procedure and the possible implications of the biopsy results. Anxiety and fear are normal responses to the need for a breast biopsy, but these responses may interfere with the woman’s ability to recall and understand the information that is provided prior to the procedure. Therefore, written information and booklets are used to reinforce teaching. The nurse also must give the patient an opportunity to address issues and concerns related to the biopsy. The nurse instructs the patient to avoid use of agents that can interfere with blood clotting and increase the risk for bleeding. Among these agents are nonsteroidal anti-inflammatory drugs, vitamin E supplements, herbal substances (such as gingko biloba and garlic supplements), warfarin, and products containing aspirin. The patient may be instructed not to eat or drink after midnight, depending on the type of biopsy planned. Most breast biopsy procedures today are performed with the use of moderate sedation and local anesthesia; thus, the recovery period is relatively brief. Postoperative assessment includes monitoring the effects of the anesthesia and inspection of the dressing covering the incision. Prior to discharge from the ambulatory surgery center or office, the patient must be able to tolerate fluids or food, ambulate, and void. The patient should be accompanied home by a family member or friend. At discharge, the nurse reviews with the patient the care of the biopsy site, pain management, and activity restrictions. The dressing covering the incision is usually removed on the second day, but use of a supportive bra is encouraged immediately after the procedure for 3 to 7 days to limit movement of the breast and reduce discomfort. Steri-strips applied over the incision are left in place until they start to come off, usually a couple of weeks after the procedure. A follow-up telephone call to the patient by the nurse 24 to 48 hours after the procedure is standard care and provides an opportunity for the nurse to answer any questions the patient might have. Most women return to their usual activities the day after the procedure but are encouraged to avoid jarring or high-impact activities for 1 week to promote healing of the biopsy site. Discomfort is usually minimal from the procedure and most women find acetaminophen sufficient for pain relief; however, a mild opioid may be prescribed, if needed. Follow-up after the biopsy includes a return visit to the surgeon for discussion of the final pathology report and assessment of the healing of the biopsy site. Depending on the results of the biopsy, the nurse’s role varies. If the pathology report is negative for cancer, the nurse reviews incision care and explains what to expect as the biopsy site heals (ie, changes in sensation may occur weeks or months after the biopsy due to injury to the nerves within the breast tissue). If a diagnosis of cancer is made, the nurse’s role changes dramatically; this is discussed in depth later in this chapter.
Overview of Breast Conditions and Diseases Not all disorders of the breast are cancerous. Some disorders are structural, such as fissure, or infection-related, such as mastitis. Some conditions may progress from a benign to a malignant condition, such as benign proliferative breast disease, and some conditions are clearly cancer of various kinds in various stages.
Conditions Affecting the Nipple FISSURE A fissure is a longitudinal ulcer that tends to develop in breastfeeding women. If the nipple becomes irritated, a painful, raw area may form and become a site of infection. Daily washing with water, massage with breast milk or lanolin, and exposure to air are helpful. Breastfeeding can continue with a nipple shield, if necessary. If the fissure is severe or extremely painful, the woman is advised to stop breastfeeding; a breast pump can be used until the breastfeeding can be resumed. Persistent ulceration requires further diagnosis and therapy. Guidance with breastfeeding from a nurse or lactation consultant may be helpful because nipple irritation can result from improper positioning (ie, the infant has not grasped the areola fully).
BREAST DISCHARGE Breast discharge in a woman who is not lactating may be related to many causes. Carcinoma, papilloma, pituitary adenoma, cystic breasts, and various medications can result in a discharge of fluid from the nipple. Oral contraceptives, pregnancy, hormone replacement therapy, chlorpromazine-type medications, and frequent breast stimulation may be contributing factors. In some athletic women, breast discharge may occur during running or aerobic exercises. Breast discharge should be evaluated by the health care provider, but it is not often a cause for alarm. One in three women have clear discharge on expression, which is usually normal. Causes for concern are green discharge, which usually indicates infection, and brown or red discharge, which is indicative of a disorder. Spontaneous discharge should always be evaluated because it is not normal unless a woman is lactating. The discharge is examined for fat globules to determine if it is breast milk. It is also tested for occult blood because malignancy must be considered.
BLEEDING OR BLOODY NIPPLE DISCHARGE At times, a bloody discharge may be produced when pressure is placed on one area at the edge of the areola. Although a bloody discharge can signal a malignancy, it usually results from a wartlike, benign epithelial tumor or papilloma growing in one of the large collecting ducts just at the edge of the areola or in an area of cystic disease. Bleeding occurs with any trauma, and the blood collects in the duct until it is pressed out at the nipple. Treatment includes excision of the duct with the papilloma. Such a lesion is usually benign, but it should be evaluated histologically after it is removed to rule out malignancy.
Breast Infections MASTITIS Mastitis, an inflammation or infection of breast tissue, occurs most commonly in breastfeeding women, although it may also occur in nonlactating women. The infection may result from a transfer of microorganisms to the breast by the patient’s hands or those of others or from a breastfed infant with an oral, eye, or skin infection. Mastitis may also be caused by bloodborne organisms. As inflammation progresses, an infection of the ducts results, causing milk to stagnate in one or more of the lobules. The breast
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texture becomes tough or doughy, and the patient complains of dull pain in the infected region. A nipple that is discharging purulent material, serum, or blood needs to be investigated. Treatment consists of antibiotics and local heat. A broadspectrum antibiotic agent may be prescribed for 7 to 10 days. The patient should wear a snug bra and perform personal hygiene carefully. Adequate rest and hydration are important aspects of management.
LACTATIONAL ABSCESS A breast abscess may develop as a consequence of acute mastitis. In such a case, the area affected becomes tender and red. Purulent matter can usually be expressed from the nipple, and incision and drainage are usually required. At the time of drainage, specimens are obtained for culture.
Benign Conditions of the Breast Benign breast lesions include fibrocystic changes, fibroadenomas, and cysts.
FIBROCYSTIC BREAST CHANGES Fibrocystic breast changes occur as ducts dilate and cysts form. This condition occurs most commonly in women ages 30 to 50 years. Although the cause is unknown, estrogen appears to be a factor because cysts usually disappear after menopause. Cystic
Table 48-1
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areas often fluctuate in size, depending on the menstrual cycle. They are usually larger premenstrually and smaller postmenstrually because of the retention of fluid in the days preceding the menstrual period. The cysts may be painless or may become very tender premenstrually. Occasionally, a patient may report breast pain, which is usually intermittent and can be shooting or a dull ache (Table 48-1 describes various breast masses). Breast pain (mastalgia) is usually related to hormonal fluctuations and their effect on the breasts or is stimulated by irritation of a nerve in the chest wall from an activity such as weight training.
Medical Management If pain and tenderness are severe, danazol (Danocrine) may be prescribed; this agent has an antiestrogenic effect, therefore decreasing breast pain and nodularity. Danazol is used only in severe cases because of its potential side effects, which include flushing, vaginitis, and androgenic changes (virilization).
Nursing Management The nurse may recommend that the patient wear a supportive bra both day and night for a week except during bathing, decrease her salt and caffeine intake, and take ibuprofen (Motrin, Advil) as needed for its anti-inflammatory actions. Vitamin E supplements or oil of evening primrose (an over-the-counter herbal preparation) may also be helpful, but this recommendation is based on anecdotal information from patients, not on research.
• Variations in Breast Masses
The most common breast masses are due to fibrocystic changes, fibroadenomas, or malignancy. Biopsy is usually needed for confirmation, but the following characteristics are diagnostic clues: CHARACTERISTICS
FIBROCYSTIC CHANGES
FIBROADENOMAS
MALIGNANCY
30–60 years, regress after menopause except with use of estrogen therapy Single or multiple Round Soft to firm, usually elastic Mobile Usually tender Absent
Puberty to menopause
30–90 years; most common, 40–80 years
Usually single Round, disk, or lobular Usually firm Mobile Usually nontender Absent
Usually single Irregular or stellate Firm or hard May be fixed to skin or underlying tissues Usually nontender May be present
(Illustrations show how the lump may feel because it is usually not visible.)
Age Number Shape Consistency Mobility Tenderness Retraction signs
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If diuretic agents or oral contraceptives are prescribed, the patient should know that symptoms usually recur after these medications are discontinued. Patients should also be reassured that breast pain is rarely indicative of cancer in its early stages. If the pain is not relieved after menses begins, however, the woman should see her primary health care provider.
FIBROADENOMAS Fibroadenomas are firm, round, movable, benign tumors of the breast that usually affect women in their late teens to late 30s. These masses are nontender and are sometimes removed for diagnostic certainty.
OTHER BENIGN CONDITIONS Cystosarcoma phyllodes is a fibroepithelial lesion that tends to grow rapidly. It is rarely malignant and is surgically excised. If it is malignant, mastectomy may follow. Fat necrosis is a rare condition of the breast that is often related to trauma from a blow; however, it may be indistinguishable from carcinoma, and the entire mass is usually excised. Gigantomastia or macromastia (overly large breasts) is a problem for some women. Weight loss and various medications have been tried to little avail. Reduction mammoplasty (discussed later in this chapter) is an elective procedure for the patient who is physically or emotionally distressed by this condition. Superficial thrombophlebitis of the breast (Mondor’s disease) is an uncommon condition that is usually associated with pregnancy, trauma, or breast surgery. Pain and redness occur as a result of a superficial thrombophlebitis in the vein that drains the outer part of the breast. The mass is usually linear, tender, and erythematous. Treatment consists of analgesics and heat.
BENIGN PROLIFERATIVE BREAST DISEASE The two most common diagnoses of benign proliferative breast disease found on biopsy are atypical hyperplasia and lobular carcinoma in situ. Both of these diagnoses increase a woman’s risk for the development of breast cancer. Atypical hyperplasia is an abnormal increase in the ductal or lobular cells in the breast and is usually found incidentally in mammographic abnormalities. Atypical hyperplasia increases a woman’s risk for breast cancer about 10% to 20% over a period of 10 years; the risk is greater for premenopausal women and decreases significantly after menopause (Hulka & Moorman, 2001). Lobular carcinoma in situ (LCIS) is usually an incidental finding in breast tissue because it cannot be seen on mammography and does not form a palpable lump. Historically, LCIS was considered a premalignant condition, and treatment consisted of a bilateral prophylactic mastectomy; however, current research indicates that LCIS is a marker for the risk for invasive breast cancer, which can either be ductal or lobular in origin and can develop in either breast. LCIS increases a woman’s risk for breast cancer by about 25% to 40% over a period of 25 years, and the risk does not diminish with time (Frykberg, 1999). For women at higher risk, a newer technique called ductal lavage may be used. It involves inserting a microcatheter through the nipple while instilling saline and retrieving the fluid for analysis. It has been shown to identify atypical cells in this population (Dooley, Ljung, Veronisi et al., 2001), providing women with
more information regarding their risk. This procedure, which is done in the office and is well tolerated, was found to be more useful at detecting cellular changes within the breast tissue. Continued research is needed to determine its benefit in screening and early detection for women at high risk.
Medical Management After a woman has been diagnosed with a benign proliferative condition such as atypical hyperplasia or LCIS, she has three treatment options: long-term surveillance (observation), bilateral prophylactic mastectomy (a risk-reducing surgical procedure), or chemoprevention (using a medication to decrease the risk of developing breast cancer). Each of these options may be offered by a breast specialist, usually associated with a comprehensive breast center. Most women choose surveillance and attempt to modify certain risk factors, such as diet, exercise, and alcohol consumption. For some women, however, prophylactic mastectomy may be an option (see discussion later in this chapter); taking tamoxifen (Nolvadex) may be an option for others. Tamoxifen has recently been shown to decrease the incidence of invasive breast cancer for high-risk women by 49% (Fisher, Constantino, Wickerham et al., 1998). The risks and benefits of each of these options must be explained so that the woman can make a careful decision.
Malignant Conditions of the Breast Breast cancer is a major health problem in the United States. Its overall incidence rose by 54% between 1950 and 1990. In the 1990s, the incidence leveled off and stabilized (American Cancer Society [ACS], 2002). At present, there is no cure for breast cancer. Between 1990 and 1994, the mortality for breast cancer decreased by 5.6%, the largest short-term decline in more than 40 years, suggesting that the combination of early detection and better systemic treatment options is having an effect on overall survival. Current statistics indicate that a woman’s lifetime risk for developing breast cancer is 1 in 8, but this risk is not the same for all age groups. For example, the risk for developing breast cancer by age 35 years is 1 in 622; the risk for developing breast cancer by age 60 years is 1 in 23. Approximately 80% of breast cancers are diagnosed after the age of 50. According to the American Cancer Society, more than 193,000 cases of breast cancer are diagnosed each year, with an estimated 40,000 deaths. About 1% of these cancers occur in men. Women who are diagnosed with earlystage localized breast cancer have a 5-year survival rate of 98% (ACS, 2002).
CARCINOMA IN SITU (NONINVASIVE) In situ carcinoma of the breast is being detected more frequently with the widespread use of screening mammography. Since the introduction of widespread mammographic screening over the past two decades, ductal carcinoma in situ (DCIS) has accounted for approximately 20% of diagnosed breast cancers (Winchester, Jeske & Goldschmidt, 2000). This disease is characterized by the proliferation of malignant cells within the ducts and lobules, without invasion into the surrounding tissue; therefore, it is a noninvasive form of cancer and is considered stage 0 breast cancer. There are two types of in situ carcinoma: ductal and lobular.
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Ductal Carcinoma in Situ
Medullary Carcinoma
DCIS, the more common of the two types, is divided histologically into two major subtypes (comedo and noncomedo), but there are many different forms of noncomedo DCIS. Because DCIS has the capacity to progress to invasive cancer, the most traditional treatment is total or simple mastectomy (removal of the breast only), with a cure rate of 98% to 99% (Winchester et al., 2000). The use of breast-conserving surgery for invasive cancer led to the use of breast-conservation therapy (limited surgery followed by radiation) for patients with DCIS, and this option is appropriate for localized lesions. More than half of cases of DCIS are now being treated with breast-conservation therapy; however, the rate of local recurrence is 15% to 20% (Solin, Fourquet, Vicini et al., 2001). In some cases, lumpectomy alone is an option, but this is decided on a case-by-case basis. In 1999, a large study demonstrated that tamoxifen (Nolvadex) significantly reduced local recurrence rates (Fisher, Dignam, Wolmark et al., 1999). Following this, the FDA approved the use of tamoxifen for women with DCIS after treatment with surgery and radiation. It is usually prescribed for 5 years.
Medullary carcinoma constitutes about 6% of breast cancers and grows in a capsule inside a duct. This type of tumor can become large, but the prognosis is often favorable.
Lobular Carcinoma in Situ LCIS is characterized by proliferation of cells within the breast lobules. LCIS is usually an incidental finding discovered on pathologic evaluation of a breast biopsy for a breast change noted during physical examination or on screening mammography. It is commonly associated with multicentric disease and is rarely associated with invasive cancer. Historically, treatment was bilateral total mastectomy, but current thinking that LCIS is a marker of increased risk for the development of an invasive cancer (rather than an actual malignancy) has changed this approach. Long-term surveillance is one appropriate option. Another option is a bilateral prophylactic mastectomy to decrease risk; current research (Hartmann et al., 1999) suggests that a 90% reduction in risk is possible with this option. (Prophylactic mastectomy is discussed in more detail at the end of this chapter.) The other treatment option for LCIS is chemoprevention. In fall 1998, the FDA approved the use of tamoxifen (Nolvadex) as a chemopreventive agent prescribed for 5 years for women at high risk; however, as with any drug, tamoxifen has both benefits and risks, along with possible side effects.
INVASIVE CARCINOMA Infiltrating Ductal Carcinoma Infiltrating ductal carcinomas are the most common histologic type of breast cancer and account for 75% of all breast cancers. These tumors are notable because of their hardness on palpation. They usually metastasize to the axillary nodes. Prognosis is poorer than for other cancer types.
Infiltrating Lobular Carcinoma Infiltrating lobular carcinoma accounts for 5% to 10% of breast cancers. These tumors typically occur as an area of ill-defined thickening in the breast, as compared with the infiltrating ductal types. They are most often multicentric; that is, several areas of thickening may occur in one or both breasts. Infiltrating ductal and infiltrating lobular carcinomas usually spread to bone, lung, liver, or brain, whereas lobular carcinomas may metastasize to meningeal surfaces or other unusual sites.
Mucinous Cancer Mucinous cancer accounts for about 3% of breast cancers. A mucin producer, it is also slow-growing and thus has a more favorable prognosis than many other types.
Tubular Ductal Cancer Tubular ductal cancer accounts for only 2% of cancers. Because axillary metastases are uncommon with this histology, prognosis is usually excellent.
Inflammatory Carcinoma Inflammatory carcinoma is a rare type of breast cancer (1% to 2%) with symptoms different from those of other breast cancers. The localized tumor is tender and painful, and the skin over it is red and dusky. The breast is abnormally firm and enlarged. Often, edema and nipple retraction occur. These symptoms rapidly grow more severe and usually prompt the woman to seek health care sooner than the woman with a small breast mass. The disease can spread to other parts of the body rapidly; chemotherapeutic agents play a major role in attempting to control the progression of this disease. Radiation and surgery are also used to control spread.
Paget’s Disease Paget’s disease of the breast accounts for 1% of diagnosed breast cancer cases. A scaly lesion and burning and itching around the nipple–areola complex are frequent symptoms. The neoplasm is ductal and may be in situ alone or may also have invasive cancer cells. Often, a tumor mass cannot be palpated underneath the nipple where this disease arises. Mammography may be the only diagnostic test that detects the tumor, but results of the mammogram are often negative, making biopsy of the lesion the only definitive test.
Current Research in Breast Cancer Because of the incidence, significant mortality, and lack of a cure, breast cancer survivors, advocates, and activists have brought social and political attention to this disease and put it in the national spotlight. Activists have demanded and obtained increased federal funding for a national program aimed at finding a cure for breast cancer. Preventing the development of cancer through the use of medications is a relatively new and exciting area of research. In April 1998, the results of the Breast Cancer Prevention Trial were released to the general public. This nationwide, randomized, double-blind, placebo-controlled clinical trial evaluated tamoxifen (Nolvadex) versus a placebo in more than 13,000 women considered to be at high risk for the development of breast cancer. The women who received tamoxifen had a 45% reduction in the incidence of breast cancer (Fisher et al., 1998). These results suggested that tamoxifen was an effective chemopreventive agent. Much attention has been focused on this medication, and it is
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now available with FDA approval for high-risk women. Clinicians are still unclear, however, about who should receive the medication, and no consensus exists. Nurses can provide information to patients on the benefits, risks, and possible side effects of tamoxifen to help women in considering this option. Another agent that shows promise for chemoprevention is raloxifene (Evista). This medication is FDA approved for the prevention of osteoporosis; however, in the studies that have been performed, incidental findings indicated that fewer of the women who received raloxifene developed breast cancer (Cummings, Eckert, Kreuger et al., 1999). This has led to the hypothesis that this drug may also be an effective chemopreventive agent. Researchers are conducting another nationwide, randomized clinical trial, the Study of Tamoxifen and Raloxifene, which is comparing these two agents in postmenopausal women for the prevention of breast cancer. Twenty-two thousand women are needed for this trial, so results will not be available until later in the decade.
Prophylactic Mastectomy Some women who are at high risk for breast cancer may elect to undergo prophylactic mastectomy. This procedure can reduce the risk for cancer by 90% (Hartmann et al., 1999; MeijersHeijboer, van Geel, van Putten et al., 2001), so a more appropriate term for this surgery is “risk-reducing” mastectomy. The procedure, performed by a breast surgeon, consists of a total mastectomy (removal of breast tissue only). Possible candidates are women with a strong family history of breast cancer, a diagnosis of LCIS or atypical hyperplasia, a diagnosis of BRCA-1 or BRCA-2 gene mutation (see following discussion), an extreme fear of cancer (“cancer phobia”), or previous cancer in one breast. Many women opt for immediate reconstruction with the mastectomy. The woman needs to understand that this surgery is elective and not emergent. To be sure that she understands the implications of surgery, the woman should be offered a consultation with a plastic surgeon, a genetic counseling session, and a psychological evaluation. Women who make an informed decision tend to demonstrate more satisfaction with the cosmetic results (Rowland, Desmond, Meyerowitz et al., 2000). Nursing interventions for the woman considering a riskreducing mastectomy include ensuring that the patient has information about reconstructive options and providing referrals to the plastic surgeon, genetic counselor, and psychological counselor. Many women need time to think over the procedure, and the nurse can be helpful in answering questions about the procedure and its implications and in assisting the patient to decide whether the surgery is an appropriate option. The woman considering this option may wish to talk with a woman who has had the procedure.
Breast Cancer There is no single, specific cause of breast cancer; rather, a combination of hormonal, genetic, and possibly environmental events may contribute to its development.
Etiology Hormones produced by the ovaries have an important role in breast cancer. Two key ovarian hormones, estradiol and progesterone, are altered in the cellular environment by a variety of factors, and these may affect growth factors for breast cancer.
HORMONES The role of hormones and their relationship to breast cancer remain controversial. Research suggests that a relationship exists between estrogen exposure and the development of breast cancer. In laboratory studies, tumors grow much faster when exposed to estrogen, and epidemiologic research suggests that women who have longer exposure to estrogen have a higher risk for breast cancer. Early menarche, nulliparity, childbirth after 30 years of age, and late menopause are known but minor risk factors. The assumption is that these factors are all associated with prolonged exposure to estrogen because of menstruation. The theory is that each cycle (which has high levels of endogenous estrogen) provides the cells of the breast another chance to mutate, increasing the chance for cancer to develop. Estrogen itself does not cause breast cancer, but it is associated with its development. GENETICS Growing evidence indicates that genetic alterations are associated with the development of breast cancer. These genetic alterations include changes or mutations in normal genes and the influence of proteins that either promote or suppress the development of breast cancer. Genetic alterations may be somatic (acquired) or germline (inherited). To date, two gene mutations have been identified that may play a role in the development of breast cancer. A mutation in the BRCA-1 gene has been linked to the development of breast and ovarian cancer, whereas a mutation in the BRCA-2 gene identifies risk for breast cancer, but less so for ovarian cancer (Houshmand, Campbell, Briggs et al., 2000). These gene mutations may also play a role in the development of colon, prostate, and pancreatic cancer, but this is far from clear at present. It has been estimated that 1 of 600 women in the general population has either a BRCA-1 or BRCA-2 gene mutation. For women who carry either mutation, the risk for developing breast cancer can range from 50% to 90% (Kauff, Satagopan, Robson et al., 2002). At present, only 5% to 10% of all breast cancers are estimated to be associated with the BRCA-1 or BRCA-2 gene mutations. It is thought, however, that breast cancer is genetic and that up to 80% of women diagnosed with breast cancer before age 50 years have a genetic component to their disease (Boyd, 1996). This is believed to be linked to either unidentified BRCA-1 or BRCA-2 carriers or less penetrating genes that have yet to be identified through genetics research. A woman’s risk for either BRCA-1 or BRCA-2 should be interpreted with caution and with an exhaustive look at all her other risk factors; this is usually carried out by a genetics counselor. Abnormalities in either of the two genes can be identified by a blood test; however, women should be counseled about the risks and benefits before actually undergoing genetic testing. The risks and benefits of a positive or negative result should be explored. Treatment options for a positive result are long-term surveillance, bilateral prophylactic mastectomy, or chemoprevention with tamoxifen, as discussed previously. A positive result can cause tremendous anxiety and fear, can unleash potential discrimination in employment and insurability, and can cause a woman to search for answers that may not be available. A negative result can produce survivor guilt in a person with a strong family history of cancer. For these women, the risk for breast cancer is similar to that of the general population, and routine screening guidelines should be followed. The decision to pursue genetic testing must be made carefully, and women should be asked what they will do differently after they know the results. Furthermore, because
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testing is relatively new and health care providers have yet to determine a true benefit from a positive or negative result, genetic testing should be done under the auspices of clinical research protocols to protect the patient (because these data are kept separate from the patient’s medical record). Nurses play a role in educating patients and their family members about the implications of genetic testing. Ethical issues related to genetic testing include possible employment discrimination, bias in insurability and possibly with insurance rates, and family members’ concerns (eg, effect on siblings, children).
Risk Factors Although there are no specific known causes of breast cancer, researchers have identified a cluster of risk factors (Chart 48-3). These factors are important in helping to develop prevention programs. However, nearly 60% of women diagnosed with breast cancer have no identifiable risk factors other than their hormonal environment (Vogel, 2000). Thus, all women are considered at risk for developing breast cancer during their lifetime. Nonetheless, identifying risk factors provides a means for identifying women who may benefit from increased surveillance and early treatment. In addition, further research into risk factors will help in developing strategies to prevent or modify breast cancer in the future. A high-fat diet was once thought to increase the risk of breast cancer. Epidemiologic studies of American and Japanese women showed that American women had a fivefold higher rate of breast cancer. Japanese women who moved to the United States were shown to have breast cancer rates similar to their Caucasian counterparts. Recent cohort studies show only weak or inconclusive relationships between a high-fat diet and breast cancer (Brown et al., 2001). Because fat intake is implicated in colon cancer and heart disease, however, women may benefit from lowering their intake of fat. Oral contraceptives were once thought to increase the risk for breast cancer. Currently, no association is thought to exist in women in the general population, but there are no data about the effect on women considered to be at high risk. The role of smoking in breast cancer remains unclear. Most studies suggest that smoking does not increase a woman’s risk for breast cancer. Some studies, however, suggest that smoking does increase the risk for breast cancer and that the earlier a woman begins smoking, the higher her risk. Smoking does increase the risk for lung cancer, which is the leading cause of death in women with cancer (breast cancer is second). Smoking cessation is part of a healthy lifestyle, and nurses have a key role in providing women with information about smoking cessation programs. Silicone breast implants can be associated with fibrous capsular contraction, and some women and medical professionals have claimed an association with certain immune disorders. There is no evidence, however, that breast implants are associated with an increased risk of breast cancer.
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Chart 48-3
Risk Factors for Breast Cancer BRCA-1 or BRCA-2 genetic mutation Women with gene mutation have a 50% to 90% chance of developing breast cancer and a 50/50 possibility of developing breast cancer before 50 years of age Increasing age Greatest risk for breast cancer occurs after age 50. Personal or family history of breast cancer Risk of developing breast cancer in the other breast increases about 1% per year. Risk increases twofold if first-degree female relatives (sister, mother, or daughter) had breast cancer Risk increases if the mother was affected with cancer before 60 years of age. Risk increases four to six times if breast cancer occurred in two first-degree relatives. Early menarche Menses beginning before 12 years of age Nulliparity and late maternal age at first birth Women having their first child after 30 years of age have twice the risk for breast cancer as women having first child before 20 years of age. Late menopause Menopause after 55 years of age but women with bilateral oophorectomy before 35 years of age have one third the risk. History of benign proliferative breast disease Risk doubles in women with benign tumors with proliferative epithelial changes; risk quadruples with atypical hyperplasia or LCIS. Exposure to ionizing radiation between puberty and 30 years of age. Risk doubles; exposure to radiation causes potential aberrations while the breast cells are developing. Obesity Weak risk among obese postmenopausal women: estrogen is stored in body adipose tissue, and dietary fat increases pituitary prolactin, thus increasing estrogen production. Obese women diagnosed with breast cancer have a higher mortality rate, which may be related to these hormonal influences or perhaps a delayed diagnosis. Hormone replacement therapy Reported risk for breast cancer related to hormone replacement therapy varies. Older women taking estrogen supplements for more than 5 years may have an increased risk; addition of progesterone to estrogen replacement decreases the incidence of endometrial cancer, but it does not decrease the risk of breast cancer. Alcohol intake As a risk factor, alcohol use remains controversial; however, a slightly increased risk is found in women who consume even one drink daily. The risk doubles among women drinking three drinks daily. In countries where wine is consumed daily (eg, France and Italy), the rate is slightly higher. Some research findings suggest that young women who drink alcohol are more vulnerable in later years.
Protective Factors Certain factors may be protective in relation to the development of breast cancer. Regular, vigorous exercise has been shown to decrease risk, perhaps because it can delay menarche, suppress menstruation, and, like pregnancy, reduce the number of ovulatory menstrual cycles. Also, exercise decreases body fat, where estrogens are stored and produced from other steroid hormones. Thus, decreased body fat can decrease extended exposure to estrogen.
Breastfeeding is also thought to decrease risk because it prevents the return of menstruation, again decreasing exposure to endogenous estrogen. Having had a full-term pregnancy before the age of 30 years is also thought to be protective. Protective hormones are released after delivery of the fetus, with the purpose of reverting to normal the proliferation of cells in the breast that occur with pregnancy.
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Clinical Manifestations Breast cancers occur anywhere in the breast, but most are found in the upper outer quadrant, where most breast tissue is located. Generally, the lesions are nontender rather than painful, fixed rather than mobile, and hard with irregular borders rather than encapsulated and smooth. Complaints of diffuse breast pain and tenderness with menstruation are usually associated with benign breast disease. Marked pain at presentation, however, may be associated with breast cancer in the later stages. With the increased use of mammography, more women are seeking treatment at an earlier stage of disease. These women may have no symptoms and no palpable lump, but abnormal lesions are detected on mammography. Unfortunately, many women with advanced disease seek initial treatment only after ignoring symptoms. For example, they may seek attention for dimpling or for a peau d’orange (orange-peel) appearance of the skin (a condition caused by swelling that results from obstructed lymphatic circulation in the dermal layer). Nipple retraction and lesions fixed to the chest wall may also be evident. Involvement of the skin is manifested by ulcerating and fungating lesions. These classic signs and symptoms characterize breast cancer in the late stages. A high index of suspicion should be maintained with any breast abnormality, and abnormalities should be promptly evaluated.
helps determine the prognosis and leads to a better understanding of how the disease progresses.
Breast Cancer Staging Staging involves classifying the cancer by the extent of disease (see Fig. 48-5). Staging of any cancer is important because it helps the health care team identify and recommend the best treatment available, offer a prognosis, and compare the results of various treatment regimens. Several diagnostic tests and procedures are performed in the staging of the disease. These may include chest x-rays, bone scans, and liver function tests. Clinical staging involves the physician’s estimate of the size of the breast tumor and the extent of axillary node involvement by physical examination (palpable nodes may indicate progression of the disease) and mammography. After the diagnostic workup and the definitive surgical treatment, the breast cancer is staged according to the TNM system (Greene, Page, Fleming, et al., 2002), which evaluates the size of the tumor, number of nodes involved, and evidence of distant metastasis. Pathologic staging based on histology provides information for a more accurate prognosis. Table 48-2 lists typical treatment guidelines by stage at diagnosis (see the following management section for details regarding these treatments).
Prognosis Assessment and Diagnostic Findings Techniques to determine the histology and tissue diagnosis of breast cancer include FNA, excisional (or open) biopsy, incisional biopsy, needle localization, core biopsy, and stereotactic biopsy (all described previously). In addition to the staging criteria described below, other pathologic features and prognostic tests are used to identify different patient groups that may benefit from adjuvant treatment. Histologic examination of the cancer cells
Stage I: Tumors are less than 2 cm in diameter and confined to breast.
FIGURE 48-5
Stage II: Tumors are less than 5 cm, or tumors are smaller with mobile axillary lymph node involvement.
Stages of breast cancer.
Several features of breast tumors contribute to the prognosis. Generally, the smaller the tumor, the better the prognosis. Carcinoma of the breast is not a pathologic entity that develops overnight. It starts with a genetic alteration in a single cell. It can take about 16 doubling times for a carcinoma to become 1 cm or larger, at which point it becomes clinically apparent. Assuming that it takes at least 30 days for each doubling time, it would take a minimum of 2 years for a carcinoma to become palpable. This
Stage IIIa: Tumors are greater than 5 cm, or tumors are accompanied by enlarged axillary lymph nodes fixed to one another or to adjacent tissue.
Stage IIIb: More advanced Stage IV: All tumors with lesions with satellite nod- distant metastases. ules, fixation to the skin or chest wall, ulceration, edema, or with supraclavicular or intraclavicular nodal involvement.
Chapter 48
Table 48-2
Assessment and Management of Patients With Breast Disorders
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• Breast Cancer Treatment Guidelines by Stage at Diagnosis
STAGE
TUMOR
SURGERY
CHEMOTHERAPY
RADIATION
0 I II III
DCIS 0–2 cm 2–5 cm >5 cm
TM or lumpectomy BCT or MRM BCT or MRM MRM
Tamoxifen Considered for all invasive tumors Regimen depends on tumor size and nodal status Postoperative and possibly preoperative
IV
Metastatic disease
Possible lumpectomy or MRM
To control progression and/or palliation
For lumpectomy For BCT For BCT To chest wall and possibly axillae after MRM To control progression and/or palliation
DCIS, ductal carcinoma in situ; TM, total mastectomy; BCT, breast-conservation treatment (lumpectomy and axillary dissection); MRM, modified radical mastectomy.
concept is important for nurses in teaching and counseling patients because once breast cancer is diagnosed, women have a safe period of several weeks to make a decision regarding treatment. The prognosis also depends on whether the cancer has spread. For example, the overall 5-year survival rate is greater than 98% when the tumor is confined to the breast (ACS, 2002). When the cancer cells have spread to the regional lymph nodes, however, the overall 5-year survival rate falls to 76%. The 5-year survival rate for women diagnosed with metastatic disease is 16%. At diagnosis, about 37% of patients have evidence of regional or distant spread or metastasis. The most common route of regional spread is to the axillary lymph nodes. Table 48-3 describes the relationship between positive axillary lymph nodes and the risk for breast cancer recurrence. Other sites of lymphatic spread include the internal mammary and supraclavicular nodes (Fig. 48-6). Distant metastasis can affect any organ, but the most common sites are bone (71%), lung (69%), liver (65%), pleura (51%), adrenals (49%), skin (30%), and brain (20%) (Winchester & Cox, 1998). In addition to tumor size, nodal involvement, evidence of metastasis, and histologic type, other measures help in determining prognosis. The presence of estrogen and progesterone receptor proteins indicates retention of regulatory controls of the mammary epithelium. The presence of both receptor proteins is associated with an improved prognosis; their absence is associated with a poorer prognosis. Similarly, a tumor with a high degree of differentiation is associated with a better prognosis than a poorly differentiated anaplastic tumor. The assessment of a tumor’s proliferative rate (S-phase fraction) and DNA content (ploidy) by laboratory assay may help to determine prognosis because these two factors are strongly correlated with other prognostic factors, and research is ongoing to examine how helpful these two factors may actually be. Tumors classified as diploid (normal DNA content) are associated with a better prognosis than are tumors classified as aneuploid (abnormal DNA content).
Table 48-3
• Relationship Between Positive Axillary Lymph Nodes and Risk for Breast Cancer Recurrence*
NO. OF POSITIVE AXILLARY LYMPH NODES
0 1–3 4–9 >10 *At 5 years’ follow-up.
RISK FOR BREAST CANCER RECURRENCE (%)
50
Medical Management CHANGING APPROACHES In 1990, the National Institutes of Health Consensus Development Conference on Breast Cancer issued its third statement on the management of breast cancer. Based on worldwide data, breastconserving surgery (such as lumpectomy), along with radiation therapy, was found to result in a survival rate equal to that of modified radical mastectomy. In addition, recommendations were made for systemic treatment with chemotherapy based on the patient’s menopausal status and the presence of hormone receptors. For a premenopausal woman without involvement of the lymph nodes, adjuvant chemotherapy was recommended if the woman was at high risk for recurrence. For a postmenopausal woman without involvement of the lymph nodes, adjuvant chemotherapy was not recommended regardless of hormonal receptor status. For a premenopausal woman with involvement of the nodes, adjuvant chemotherapy was recommended. In a postmenopausal woman, hormone therapy was recommended if the woman had an estrogen receptor-positive tumor. The section on hormonal therapy later in this chapter describes this in more depth. In 1991, the National Cancer Institute issued a clinical alert that altered the recommendations of the 1990 Consensus Development Conference Statement. This alert recommended that all premenopausal, node-negative women at high risk for recurrent disease receive adjuvant chemotherapy. This clinical alert was issued before the results of clinical trials were published, creating confusion among clinicians and patients alike. The 2000 Consensus Development Conference Statement stated that all women with invasive breast cancer should consider systemic chemotherapy, not just women with tumors larger than 1 cm (NIH, 2000). Decisions regarding local treatment with either mastectomy or breast-conserving surgery with radiation still vary widely. Mastectomy is still performed in many cases, and rates for breastconserving surgery are higher in metropolitan areas with teaching and research hospitals and medical centers. In the past, women have not routinely been presented with the option of breastconserving surgery by their physicians, and in many instances insurance reimbursement patterns favor mastectomy. Thus, women have not uniformly had the opportunity to exercise informed choice in their options for local treatment, but this is changing as women become more knowledgeable about breast cancer and its treatment. A second opinion regarding treatment options is usually helpful to women diagnosed with breast cancer. SURGICAL MANAGEMENT The main goal of surgical treatment is to eradicate the local presence of the cancer. The procedures most often used for the local
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Intraclavicular nodes Lower deep cervical lymph nodes drain into venous system Interpectoral nodes Internal mammary lymph nodes drain medial part of breast Subareolar plexus
FIGURE 48-6
• Surgical Treatment of Breast Cancer
SURGICAL PROCEDURE
DESCRIPTION
Breast-conserving procedures: Lumpectomy Wide excision Partial mastectomy Segmental mastectomy Quadrantectomy
Relatively synonymous terms to describe removal of varying amounts of breast tissue, including the malignant tissue and some surrounding tissue to ensure clear margins; axillary lymph nodes are also removed with these procedures, if the cancer was of the invasive type Removal of some or all fat-enmeshed axillary lymph nodes for determination of extent of disease spread; the single most important determinant for prognosis and for need for adjuvant treatment Removal of the breast tissue only; this procedure is generally done for the treatment of carcinoma in situ, typically ductal Removal of the breast tissue and an axillary lymph node dissection; the pectoralis major and minor muscles remain intact Removal of the breast tissue along with pectoralis major and minor muscles in conjunction with an axillary lymph node dissection
Axillary lymph node dissection
Total mastectomy
Modified radical mastectomy Radical mastectomy
Central axillary nodes Posterior axillary nodes Apical axillary nodes
Anterior (pectoral) axillary nodes
Lymphatic drainage of the breast.
management of invasive breast cancer are mastectomy with or without reconstruction and breast-conserving surgery combined with radiation therapy. These procedures are described below. Surgical treatment options are summarized in Table 48-4. For patients who undergo total mastectomy for the treatment of DCIS or as prophylactic surgery for the treatment for LCIS, the nursing care is similar to that of a modified radical mastectomy (described later in the text). However, total mastectomy does not involve the
Table 48-4
Lateral axillary nodes
removal of axillary lymph nodes; therefore, mobility of the arm on the affected side is regained much quicker, and there is no risk for lymphedema. Women still face the same psychosocial issues involving the diagnosis of cancer and the loss of the breast, and the nurse needs to address these in a similar manner. Modified Radical Mastectomy. Modified radical mastectomy is removal of the entire breast tissue, along with axillary lymph nodes. The pectoralis major and pectoralis minor muscles remain intact. Before surgery, the surgeon plans an incision that will provide maximum opportunity to remove the tumor and the affected nodes. At the same time, efforts are made to avoid a scar that will be visible and restrictive. An objective of surgical treatment is to maintain or restore normal function to the hand, arm, and shoulder girdle on the affected side. Skin flaps and tissue are handled with great care to ensure proper viability, hemostasis, and drainage. If reconstructive surgery is planned, a consultation is made with a plastic surgeon before the mastectomy is performed. After the tumor is removed, bleeding points are ligated and the skin is closed over the chest wall. Skin grafting is performed if the skin flaps are too small to close the wound. A nonadherent dressing (Adaptic) may be applied and covered by a pressure dressing. Two drainage tubes may be placed in the axilla and beneath the superior skin flap, and portable suction devices may be used; these remove the blood and lymph fluid that collect after surgery. The dressing may be held in place by wide elastic bandages or a surgical bra. Breast-Conserving Surgery. Breast-conserving surgery consists of lumpectomy, wide excision, partial or segmental mastectomy, or quadrantectomy (resection of the involved breast quadrant) and removal of the axillary nodes (axillary lymph node dissection) for tumors with an invasive component, followed by a course of radiation therapy to treat residual, microscopic disease. The goal of breast conservation is to remove the tumor completely with clear margins while achieving an acceptable cosmetic result. The axillary lymph nodes are also removed through a separate semicircular incision under the hair-bearing portion of the axilla. A drain is inserted into the axilla through a separate stab
Chapter 48
Assessment and Management of Patients With Breast Disorders
wound to remove blood and lymph fluid. A dressing is applied over the breast and under the arm and is secured with wide elastic bandages or a surgical bra. Survival rates after breast-conserving surgery are equivalent to those after modified radical mastectomy. The risk for local recurrence, however, is greater, at 1% per year after surgery (Winchester & Cox, 1998). If the patient experiences a local recurrence, standard treatment is a completion or salvage mastectomy, in which the rest of the breast tissue is removed. Survival rates after this procedure are equivalent to those after mastectomy, but because the skin has been irradiated, the choices for reconstruction remain limited, and the woman should be informed of this possibility at the time of diagnosis and when considering her treatment options. Postoperative Issues. The postoperative care of the patient undergoing a modified radical mastectomy or breast-conserving surgery is similar because both procedures involve an alteration to the breast and removal of lymph nodes from the axillary region. As with any surgical patient, the immediate focus is recovery from general anesthesia and pain management. In addition, the patient who has had breast surgery may experience both physical and psychological effects. Possible complications include the accumulation of blood (hematoma) at the incision site, infection, and late accumulation of serosanguineous fluid (seroma) after drain removal. Most patients who undergo breast surgery are discharged home with a drainage collection device in place. The nurse teaches the patient and family members to manage the drainage system. Nerve trauma with resultant phantom breast sensations, numbness, tingling, or burning sensations may also occur and may persist for months or possibly years after surgery. Impaired arm and shoulder mobility can result from the axillary dissection. The disruption of lymphatic and venous drainage can leave the patient at risk for lymphedema (chronic swelling of the affected extremity) at any point after surgery (discussed later in this chapter). Psychological sequelae may include an altered body image or selfconcept as a result of the alteration or loss of the breast. Other major psychosocial concerns include uncertainty about the future, fear of recurrence, and the effects of breast cancer and its treatment on family and work roles. Lymphatic Mapping and Sentinel Node Biopsy. In the mid 1990s, a new procedure was introduced for use in patients undergoing breast surgery for the treatment of invasive breast cancer. Approximately 60% of patients who undergo an axillary lymph node dissection to determine the extent of the disease have negative nodes (Veronesi, Galimberti, Zurrida et al., 2001). The use of lymphatic mapping and sentinel node biopsy is changing the way these patients are treated because it provides the same prognostic information as the axillary dissection. A radiocolloid and/or blue dye is injected into the tumor site; the patient then undergoes the surgical procedure. The surgeon uses a hand-held probe to locate the sentinel node (the primary drainage site from the breast) and excises it, and it is examined by the pathologist. If the sentinel node is negative for metastatic breast cancer, a standard axillary dissection is not needed, thus sparing the patient the sequelae of the procedure (surgical drain, altered mobility of the extremity, paresthesias, risk for lymphedema). If the sentinel node is positive, the patient undergoes the standard axillary dissection. Reported results of this technique suggest a success rate of more than 90% in correctly identifying the sentinel node and correctly predicting axillary metastases (Hsueh, Hansen & Guiliano, 2000), and many centers have incorporated this procedure into stan-
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dards of care. Short-term follow-up demonstrates that the rate of lymphedema is approximately 1% for women who undergo sentinel lymph node biopsy. Nursing issues for this procedure focus on informing the patient about the expectations and possible implications. Because patients with a negative node are spared the axillary dissection, they may be discharged home the same day. Research is needed on the technique’s sequelae, however. Questions to be addressed include: Do patients experience similar sensations in the affected arm as those who had an axillary dissection? Do patients demonstrate impaired mobility? Do these patients develop axillary seromas after the procedure? What is the risk for lymphedema? Initial nursing research on patient care issues related to sentinel node biopsy demonstrates that women who have sentinel node biopsy alone do have neuropathic sensations similar to those who undergo an axillary dissection, although the prevalence, severity, and distress are less so (Baron, Fey, Raboy et al., 2002). RADIATION THERAPY With breast-conserving surgery, a course of external-beam radiation therapy usually follows excision of the tumor mass to decrease the chance of local recurrence and to eradicate any residual microscopic cancer cells. Radiation treatment is necessary to obtain results equal to those of removal of the breast. If radiation therapy is contraindicated, mastectomy is the patient’s only option (Chart 48-4). Radiation treatment typically begins about 6 weeks after the surgery to allow the incision to heal. If systemic chemotherapy is indicated, radiation therapy usually begins after completion of the chemotherapy. External-beam irradiation provided by a linear accelerator using photons is delivered on a daily basis over 5 to 7 weeks to the entire breast region. In addition, a concentrated radiation dose or “boost” is administered to the primary site by means of electrons. Before radiation therapy begins, the patient undergoes a planning session for radiation treatment that will serve as the model for daily treatments. Small permanent ink markings are used to identify the breast tissue to be irradiated. Patients need reassurance about the procedure and self-care instructions related to side effects and their management. Postoperative radiation after mastectomy is not common today but is still used in certain cases: when tumors have spread regionally (chest wall involvement, four or more positive nodes, or tumors larger than 5 cm). Occasionally, patients who have had a mastectomy require radiation treatment to the chest wall, generally after completion of systemic chemotherapy. Treatment usually consists of a course of external-beam irradiation to the area
Chart 48-4
Contraindications to Breast-Conservation Treatment
Note: Breast-conservation treatment includes both surgery and radiation. Absolute Contraindications • First or second trimester of pregnancy • Presence of multicentric disease in the breast • Prior radiation to the breast or chest region Relative Contraindications • History of collagen vascular disease • Large tumor-to-breast ratio • Tumor beneath nipple
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for a period of several weeks, but the time frame is determined by the radiation oncologist. Some studies suggest that survival may be enhanced for high-risk premenopausal women who receive chest wall irradiation after mastectomy. Another approach to radiation therapy is the use of intraoperative radiation therapy (IORT), in which a single dose of radiation is delivered to the lumpectomy site immediately after the surgeon has performed the lumpectomy. The dosage is limited to the tumor area, as any errant cells are most likely to be within the approximate area. The typical side effects of skin changes and fatigue are minimized with this approach. It may be as effective as the standard 5- to 7-week radiation course, but long-term data are still needed to determine the effect on local recurrence and survival rates. Postirradiation Reaction. Generally, radiation therapy is well tolerated. Side effects are temporary and usually consist of mild to moderate skin reaction and fatigue. Fatigue usually occurs about 2 weeks after treatment and may last for several weeks after the treatments are completed. Fatigue can be depressing, as can the frequent trips to the radiation oncology unit or department for treatment. The patient needs to be reassured that the fatigue is normal and not a sign of recurrence. Rare complications of radiation therapy to the breast include pneumonitis, rib fracture, and breast fibrosis. Postirradiation Nursing Management. Self-care instructions for patients receiving radiation are based on maintaining skin integrity during and after radiation therapy:
• Use mild soap with minimal rubbing. • Avoid perfumed soaps or deodorants. • Use hydrophilic lotions (Lubriderm, Eucerin, Aquaphor) for dryness.
• Use a nondrying, antipruritic soap (Aveeno) if itching occurs. • Avoid tight clothes, underwire bras, excessive temperatures, and ultraviolet light.
Patients may note increased redness and, rarely, skin breakdown at the booster site (tissue site that received concentrated radiation). Important aspects of follow-up care include teaching patients to minimize exposure of the treated area to the sun for 1 year and reassurance that minor twinges and shooting pain in the breast are normal reactions after radiation treatment. CHEMOTHERAPY Chemotherapy is administered to eradicate the micrometastatic spread of the disease. An overview of chemotherapy is presented in Chapter 16. Although chemotherapy is generally initiated after breast surgery, no single standard exists for the sequencing of systemic chemotherapy and radiation therapy. Ongoing clinical trials may help to determine which treatment sequence produces the best outcomes. Chemotherapy regimens for breast cancer combine several agents to increase tumor cell destruction and to minimize medication resistance. The chemotherapeutic agents most often used in combination are cyclophosphamide (Cytoxan) (C), methotrexate (M), fluorouracil (F), and doxorubicin (Adriamycin) (A). Paclitaxel (Taxol) (T) has been recently introduced into the adjuvant chemotherapy setting, and the data from clinical trials suggest a slight survival benefit with its use (Norton, 2001). Additionally, a newer taxane, docetaxel (Taxotere) (T), is being used more frequently, but research remains limited on its difference. The combination regimen of CMF or CAF is a common treat-
ment protocol. AC, ACT (AC given first followed by T), and ATC, with all three agents given together, are other regimens that may be used (Levine, 2001). A new anthracycline agent, epirubicin (Ellence), which has been used more in Europe, is being used in certain regimens and protocols. Decisions regarding the chemotherapeutic protocol are based on the patient’s age, physical status, and disease status and whether she is participating in a clinical trial. Chemotherapy treatment modalities are summarized in Table 48-5. Reactions to Chemotherapy. Anticipatory anxiety is a common response among patients facing chemotherapy. Today, however, side effects can be managed well, with many women continuing their daily work and routine schedules. This has occurred in large measure because of the meticulous educational and psychological preparation provided to patients and their families by oncology nurses, oncologists, social workers, and other members of the health care team. The other factor is the availability of medication regimens that can alleviate the side effects of nausea and vomiting. Common physical side effects of chemotherapy for breast cancer include nausea, vomiting, taste changes, alopecia (hair loss), mucositis, dermatitis, fatigue, weight gain, and bone marrow suppression. In addition, premenopausal women may experience temporary or permanent amenorrhea leading to sterility. Less common side effects include hemorrhagic cystitis and conjunctivitis. Although its cause is unknown, weight gain of more than 10 pounds occurs in about half of all patients. Aerobic exercise and its anxiety-alleviating effects may be helpful to decrease weight gain and elevate mood. Side effects may vary with the chemotherapeutic agent used. CMF is generally well tolerated with only minimal side effects. Doxorubicin can be toxic to tissue if it infiltrates the vein, so it is usually diluted and infused through a large vein. Nausea and vomiting can occur. Antiemetics and tranquilizers may provide relief, as may visual imagery and relaxation exercises. Doxorubicin and paclitaxel usually cause alopecia, so obtaining a wig before hair loss occurs may prevent some of the associated emotional trauma. The patient needs reassurance that new hair will grow when treatment is completed, although the color and texture of the hair may differ. It is helpful to provide a list of wig suppliers in the patient’s geographic region and to become familiar with creative ways to use scarves and turbans to reduce the patient’s reactions to hair loss. The American Cancer Society offers a program called “Look Good, Feel Better” that provides useful tips for applying cosmetics during chemotherapy. Nursing Management in Chemotherapy. Nurses working with patients receiving chemotherapy play an important role in assisting those who have difficulty with the side effects of treatment. Encouraging the use of medications to limit nausea, vomiting, and mouth sores reduces discomfort during chemotherapy. Some patients may receive granulocyte colony-stimulating factor (G-CSF), a synthetic growth-stimulating factor injected subcutaneously daily for 10 days, which boosts the white blood cell count to prevent nadir fever (a fever that occurs with infection when the blood cell counts are at their lowest level) and infections. The nurse instructs the patient and family on injection technique and about symptoms that require follow-up with a physician (Chart 48-5). Taking time to explain side effects and possible solutions may alleviate some of the anxiety of women who feel uncomfortable asking questions. The more informed a patient is about the side effects of chemotherapy and how to manage them, the better she can anticipate and deal with them.
Table 48-5
• Chemotherapy and Hormonal Therapy for Breast Cancer
TYPE OF TREATMENT
GOALS OF THERAPY
Chemotherapy
Destroy neoplastic cells Decrease or prevent metastasis
doxorubicin (Adriamycin) (A) cyclophosphamide (Cytoxan) (C) methotrexate (M) 5-fluorouracil (F) paclitaxel (Taxol) (T) epirubicin (Ellence) (E) docetaxel (Taxotere) (T) Combination therapy: CMF CAF AC ACT CEF
Hormonal Therapy Androgens fluorymesterone (Halotestin) Estrogens diethylstilbestrol (DES) Corticosteroids prednisone Antihormonal agents tamoxifen (Nolvadex)
megestrol acetate (Megace)
Suppress estrogens
Suppress FSH and LH Suppress estrogen production by the adrenals and decrease urinary estrogen metabolites Estrogen antagonist; effective in decreasing risk for cancer recurrence in postmenopausal women and as a palliative treatment for recurrent cancer Progestational agent; may decrease number of estrogen receptors in breast tissue
aminoglutethimide (Cytadren)
Enzyme antagonist that inhibits estrogen synthesis
anastrazole (Arimidix)
Aromatase inhibitor; blocks production of estrogen in peripheral tissues
POSSIBLE SIDE EFFECTS
NURSING INTERVENTIONS
ECG changes, tachycardia, nausea, vomiting, stomatitis, hair loss, severe cellulitis if infiltration occurs Nausea, vomiting, anorexia, menstrual abnormalities, hemorrhagic cystitis Stomatitis, CNS changes, hair loss CNS changes, neurotoxicity, nausea, vomiting, constipation, stomatitis Hypersensitivity, peripheral neuropathy, nausea, vomiting, diarrhea, stomatitis, hair loss Myelosuppression; cardiac toxicity; nausea, vomiting, and mucositis Hypersensitivity; neurosensory disturbances; nausea, vomiting, stomatitis Side effects of all agents used
Nausea and vomiting: Administer antiemetics as prescribed; monitor fluid intake and output Anorexia: Assist patient and family to identify appetizing foods; provide frequent small meals if better tolerated than three regular meals; refer to dietitian for assistance in planning palatable, nutritious meals Stomatitis: Avoid commercial mouthwashes; use baking soda, salt and water rinses, or oral anesthetic agents Hair loss: Avoid brushing, blow drying, frequent shampooing; encourage use of turbans and scarves; encourage patient to obtain wig before hair loss occurs CNS changes: Monitor for weakness, malaise, fatigue, seizures, change in cognitive status; assist with activities of daily living if fatigue and malaise occur Neurotoxicity: Monitor deep tendon reflexes, assess gait and muscle strength, monitor for changes in sensory function Fluid retention: Monitor weight, fluid intake and output, skin turgor Cardiac changes: Monitor ECG, cardiac rate and rhythm; notify physician of dysrhythmias Hypercalcemia: Monitor serum calcium levels, monitor cardiac rate and rhythm Constipation: Monitor bowel function; consider that constipation may be indicative of neurotoxicity; administer stool softeners, laxatives as prescribed; encourage adequate intake of fluids and fiber Anxiety: Administer tranquilizers as prescribed; encourage use of strategies to minimize anxiety (imagery, relaxation)
Masculinization, fluid retention, cholestatic jaundice, hypercalcemia Nausea, vomiting, anorexia, dizziness, headache Cushing’s syndrome: fullness of face, weight gain, edema of lower extremities Weight gain, hot flashes, nausea, anorexia, lethargy
Hormonal instability: Observe for changes (hot flashes, vaginal bleeding, flare); facial hirsutism, deepening of voice; fluid retention, Cushing’s syndrome (fullness of face, lower extremity edema, weight gain); increased blood pressure; assess for thrombophlebitis; monitor serum calcium levels; educate patient on symptom management of hot flashes and assure patient that most changes are temporary
Weight gain, hot flashes, vaginal bleeding, increased blood pressure, peripheral edema, depression, tumor flare CNS changes: dizziness, clumsiness, drowsiness, depression, headache Asthenia, nausea, headache, hot flashes, back pain
*This listing of medications, side effects, and nursing interventions is not meant to be exhaustive but is rather a sample of frequently used chemotherapeutic agents for breast cancer. FSH, follicle-stimulating hormone; LH, luteinizing hormone.
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Chart 48-5 Home Care Checklist • Self-Administration of G-CSF At the completion of the home care instruction, the patient or caregiver will be able to: • State the purpose for the G-CSF injections • Identify the equipment necessary for self-injection • Identify appropriate body sites for self-injection • Demonstrate how to draw up the G-CSF in a syringe • Demonstrate how to give an injection properly • State possible side effects of G-CSF treatment • State reasons for contacting the physician or nurse (eg, excessive pain, fever)
Chemotherapy may negatively affect the patient’s self-esteem, sexuality, and sense of well-being. Combined with the stress of a potentially life-threatening diagnosis, these changes can be overwhelming. Because many women are distressed by financial concerns and time spent away from the family, nursing support and teaching can reduce emotional distress during treatment. Important aspects of nursing care include communicating, facilitating support groups, encouraging patients to ask questions, and promoting trust in health care providers. Adequate time must be scheduled for clinical appointments to allow discussion and questions. Most women with breast cancer today are treated in a multidisciplinary environment, and referrals to the dietitian, social worker, psychiatrist, or spiritual advisor can assist in dealing with many of the issues of cancer treatment. In addition, numerous community supports and advocacy groups are available to these patients and their families.
Patient
Caregiver
✓ ✓ ✓ ✓ ✓ ✓ ✓
✓ ✓ ✓ ✓ ✓ ✓ ✓
HORMONAL THERAPY Decisions about hormonal therapy for breast cancer are based on the outcome of an estrogen and progesterone receptor assay of tumor tissue taken during the initial biopsy. The tissue requires special handling by laboratory technicians with expertise in assessment techniques. Normal breast tissue contains receptor sites for estrogen. About two thirds of breast cancers are estrogen dependent, or ER-positive (ER+). An ER+ assay indicates that tumor growth depends on estrogen supply; therefore, measures that reduce hormone production may limit the progression of the disease, and these receptors can be considered prognostic indicators. ER+ tumors may grow more slowly in general than those that do not depend on estrogen (ER−); thus, having an ER+ tumor indicates a better prognosis. A value less than 3 fmol/mg is considered negative. Values of 3 to 10 are questionable, and values greater than
NURSING RESEARCH PROFILE 48-2
Menopausal Symptoms During Breast Cancer Treatment McPhail, G., & Smith, L. N. (2000). Acute menopausal symptoms during adjuvant systemic treatment for breast cancer. Cancer Nursing, 6(23), 430–443.
Purpose Early detection and improved treatment of breast cancer have increased the life expectancy of women who reach menopause after the diagnosis of breast cancer to near-normal. It has been suggested that menopause experienced by women receiving treatment for breast cancer may differ from natural menopause, although no empirical study has addressed this issue. The purpose of this study was to determine if menopausal symptoms in women who were undergoing systemic chemotherapy differed from those in women who experience a natural menopause. Study Sample and Design The sample in this case-control study comprised two groups of women ranging from 50 to 64 years of age: 200 women undergoing treatment for breast cancer with tamoxifen or chemotherapy and a control group of 200 women who had undergone breast screening and had no diagnosis of breast cancer. A self-report questionnaire addressed general health and menstrual history, breast cancer treatment and associated symptoms, and menopause and menopausal symptoms. The women with breast cancer completed all portions of the questionnaire, while women without breast cancer completed only the third section, which included the Greene Climacteric Scale, an established scale for menopausal symptoms. Questionnaires were mailed to the 400 women, and 238 completed and returned the questionnaires. The final sample included 139 women with breast cancer and 99 women without a diagnosis of breast cancer. Most of the women in both groups were perimenopausal or postmenopausal at the time of the study. Statistical
procedures were used to describe study results and to examine differences between the two groups. Findings Women with breast cancer were more likely than those without cancer to report that they were currently experiencing menopause symptoms ( p = 0.04) and were more likely to have a greater severity of symptoms as assessed by the Greene Climacteric Scale. Women who were receiving adjuvant systematic treatment for breast cancer perceived their menopause symptoms as a significant source of distress, with hot flushes second to tiredness as a side effect attributed to cancer treatment. Women receiving chemotherapy were more likely to report tiredness, and women receiving tamoxifen were more likely to report hot flushes. The group undergoing treatment and the control group differed on four specific symptoms: tiredness, hot flushes, night sweats, and headaches. The women undergoing breast cancer treatment reported more severe tiredness, hot flushes, and night sweats than the control group. The control group experienced more severe headaches. Nursing Implications Nurses who care for patients undergoing systemic chemotherapy for treatment of breast cancer need to be aware of the greater potential for distressing side effects related to menopause. Management of these side effects is important to assist the woman through the treatment. Providing suggestions about strategies to manage fatigue and minimize hot flushes is an important nursing intervention.
Chapter 48
Assessment and Management of Patients With Breast Disorders
10 are considered positive. The greater the value, the more beneficial the anticipated effect from hormone suppression can be. Patients with tumors that are positive for both estrogen and progesterone (PR+) generally have a more favorable prognosis than patients with tumors that are ER− and PR−. Most progesteronereceptive tumors also have a positive estrogen receptor status. The loss of progesterone receptors can be a sign of advancing disease. Premenopausal women and perimenopausal women are more likely to have non–hormone-dependent lesions; postmenopausal women are likely to have hormone-dependent lesions. Hormonal therapy may include surgery to remove endocrine glands (eg, the ovaries, pituitary, or adrenal glands) with the goal of suppressing hormone secretion. Oophorectomy (removal of the ovaries) is one treatment option for premenopausal women with estrogen-dependent tumors. Tamoxifen is the primary hormonal agent used in breast cancer treatment today. Anastrazole (Arimidex), letrozole (Femara), leuprolide (Lupron), megestrol (Megace), diethylstilbestrol (DES), fluoxymesterone (Halotestin), and aminoglutethimide (Cytadren) are other hormonal agents used to suppress hormone-dependent tumors. Most of these agents may be associated with menopausal symptoms such as vasomotor changes. Hypercalcemia may also occur and may necessitate discontinuing the agent. These hormonal agents are described in Table 48-5. BONE MARROW TRANSPLANTATION Bone marrow transplantation (BMT) involves removing bone marrow from the patient and then administering high-dose chemotherapy. The patient’s bone marrow, spared from the effects of chemotherapy, is then reinfused intravenously. This procedure is usually performed in specialized transplantation centers, and specific patient preparation, education, and support must be given throughout the treatment course. In 1999, scientific misconduct was discovered in the only study that showed a benefit (Hagmann, 2000), casting doubt on the role that BMT may play in breast cancer treatment. The use remains controversial outside of clinical trials, since studies are not clear as to the true benefits in comparison to standard high-dose chemotherapy (Antman, 2001). BMT is described more fully in Chapter 16. INVESTIGATIONAL THERAPY: THE FUTURE Research is underway to develop chemotherapeutic agents that modify multidrug resistance and agents that enhance or modify standard chemotherapy. Research in breast cancer treatment includes the following areas: peripheral stem cell transplants, oncogenes (tumor genes that control cell growth), growth factors (substances released by cancer cells to make the environment more conducive to growth), monoclonal antibodies (synthetic antibodies that fight cancer cells), biologic response modifiers (substances that help increase the body’s immune system response), and vaccine studies. Another treatment modality that has shown promise is trastuzumab (Herceptin). This monoclonal antibody was engineered from mouse antibodies and closely resembles a human antibody. Herceptin binds with the HER2 protein, and this protein regulates cell growth, thus inhibiting tumor cell growth. For women with metastatic breast cancer, about 25% to 30% of tumors overproduce HER2, and this monoclonal antibody can slow growth and possibly stimulate the immune response. In fall 1998, the FDA approved this agent for the treatment of metastatic breast cancer. Research is ongoing, but the addition of this agent to traditional chemotherapy has shown improved survival rates in clinical trials (Capriotti, 2001). Further research and clinical
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experience will demonstrate the potential of this drug in the treatment of breast cancer, particularly on the role of Herceptin for women undergoing adjuvant therapy.
Special Issues in Breast Cancer Management RECONSTRUCTIVE SURGERY After mastectomy, some women elect to have reconstructive surgery, which provides considerable psychological benefit. Support groups and classes provide education and peer support for patients who are candidates for and interested in breast reconstruction. Some concerns that women may have about reconstructive surgery are cost, safety, and timing—whether to undergo reconstruction immediately (at the time of mastectomy) or delay it (6 months to 1 year after surgery). Cost to the patient may vary depending on her health insurance, but because reconstruction is considered rehabilitative surgery, it is often covered. In regard to safety, there are the usual surgical risks for infection and reaction to anesthesia, as well as the risk for a cosmetically unsatisfactory result. Reconstructive surgery is contraindicated if a woman has locally advanced, metastatic, or inflammatory breast cancer. Otherwise, most women with either in situ or early-stage breast cancer are candidates for immediate reconstruction. Breast reconstruction does not interfere with systemic treatment, nor does it affect the risk of cancer recurrence. If a woman decides to have reconstructive surgery at the time of mastectomy, she avoids future surgery, although the total operative time increases. Some women find that immediate reconstruction lessens the feelings of loss and disfigurement. Occasionally, reconstruction cannot be performed because skin and muscles are too tight. Loose, supple skin and subcutaneous tissue with a sufficient blood supply contribute to reconstructive success. Some women benefit by waiting until later because initially they are not sure about their choice. Reconstructive surgery is discussed in more detail later in this chapter.
PROSTHETICS Not all women desire reconstruction, nor are all women candidates for reconstructive surgery. In these instances, patients may need information about prostheses (molds made of silicone shaped in the form of a breast) and the names of shops where they can be fitted for a prosthesis. The American Cancer Society’s Reach to Recovery program can provide women with the names and addresses of local establishments where they can be fitted. Women should be encouraged to find a shop that has a comfortable, supportive atmosphere and employs a certified prosthetics consultant. Generally, medical supply shops are not recommended because they often do not have the appropriate resources to ensure the proper fit of a prosthesis. Before the patient is discharged from the hospital (following a day-surgery procedure or an overnight hospital stay), the nurse usually provides the patient with a temporary cotton fluff that can be worn until the surgical incision is well healed (4 to 6 weeks). At that time, the woman can be fitted for a prosthesis. Insurance generally covers the cost of a prosthesis and the special bras that hold it in place. Women should be encouraged to wear the prosthesis because it provides a sense of psychological restoration and wholeness. The prosthesis also assists the woman in resuming proper posture, because it helps to balance the weight of the remaining breast.
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QUALITY OF LIFE AND BREAST CANCER Despite current treatment, there has been only a slight overall improvement in survival for breast cancer patients. Consequently, quality-of-life considerations have become important issues in treatment and recovery. Quality of life is a multidimensional construct that includes functional (self-care) status, social and family functioning, and psychological and spiritual well-being. These parameters are important indicators of how well a patient is functioning after diagnosis and treatment. Breast cancer is the most frequently investigated cancer in quality-of-life studies. Early psychosocial studies emphasized that the loss of the breast was the single most important factor in women’s adjustment, especially in Western cultures. Thus, it is not surprising that studies of women’s adjustment to breast cancer found similar results. A growing body of research, however, indicates that concerns related to uncertainty about the future, day-to-day issues in work and family relationships, and demands of illness are more important factors in adjusting to having breast cancer than the loss of the breast alone. For example, younger women are more vulnerable to issues of psychosocial adjustment than many older women (Hoskins & Haber, 2000). They worry about their jobs and whether they will be able to keep their health care benefits. They are concerned about their work productivity and career advancement (Wonghongkul, Moore, Musil et al., 2000). They face many family concerns related to whether they can have children, whether they will live to see their children grow up, and whether their disease will recur and incapacitate them (Horden, 2000). Middle-aged women worry about their disease in relation to their family and work (Walker, Nail & Croyle, 1999). They also worry about their aging parents and whether they will be able to care for them in the future. They are increasingly concerned about their daughters’ risk for breast cancer. Older women are more vulnerable to chronic health problems. Living an average of 6 years longer than men, older women face loss of their social circles, must deal with the potential for other diseases, and worry about whether they will have the resources to pay for medications. These concerns are intertwined with the effects of breast cancer on the family. Studies indicate that up to 35% of families of breast cancer patients experience significant changes in family functioning. More than 25% of children also experience problems related to their mothers’ breast cancer (Hilton, Crawford & Tarko, 2000). In addition, families shoulder substantial costs in caring for family members with advanced breast cancer. These out-of-pocket, unreimbursed expenses include lost wages and salaries and lost opportunities. When faced with any life-threatening illness, spiritual and existential concerns usually surface. Patients with breast cancer often express the need to talk about the uncertainties of their future and their hope and faith that they will be able to manage whatever crisis or challenge comes their way.
PREGNANCY AND BREAST CANCER From 2% to 5% of breast cancers occur in relation to pregnancy (Dow, 2000; Moore & Foster, 2000). The potent hormones released during pregnancy (1,000 times greater than those during a menstrual cycle) stimulate changes in breast tissue (Gemignani & Petrek, 1999). Thus, detecting masses is more difficult during pregnancy. An important aspect of health promotion is to encourage BSE throughout pregnancy.
NURSING RESEARCH PROFILE 48-3
Breast Cancer Survivorship Utley, R. (1999). The evolving meaning of cancer for long-term survivors of breast cancer. Oncology Nursing Forum, 26(9), 1519–1523.
Purpose While the incidence of cancer is highest in women over 65 years of age, the highest survival rates also occur in this group, with a survival rate of 97% for localized breast cancer. Little is known about the experience of survivorship of women with breast cancer. Thus, the purpose of this study was to describe the different meanings of cancer for older women who were long-term survivors of breast cancer. Study Sample and Design A descriptive qualitative study was conducted to explore the experience of long-term survivors of breast cancer. The sample comprised eight women whose survival following treatment for breast cancer ranged from 5.5 to 29 years. Their ages at the time of the study ranged from 65 to 77 years. Four of the women had lumpectomy with radiation and chemotherapy, and one had lumpectomy with radiation only as her treatment. Three women had undergone mastectomy and one of them had received oral chemotherapy. Two of the women had positive axillary lymph nodes, and they had lumpectomy combined with radiation and chemotherapy. Interviews lasting 60 to 90 minutes were conducted with the women in their homes; three life history interviews were conducted with each woman and audiotaped. The interviews were then transcribed and coded for themes and patterns. In addition, the researcher used a methodology log and reflexive journal. Findings Three meanings of cancer emerged from the data: cancer as sickness and death, cancer as an obstacle, and cancer as transforming. Cancer as sickness and death was the initial perspective of the women at the time of diagnosis and during the early phases of their treatment. Cancer as obstacle reflected the women’s perspective that breast cancer was an obstacle that was intrusive or in the way of their life path that they had to deal with before moving on. Cancer as transforming described the change in women’s outlooks about life and their own strength as they put their diagnosis in perspective. They viewed their cancer treatment as past and moved on to renewing their interactions with their surroundings. Nursing Implications Nurses need a better understanding of and sensitivity to the experience of women with breast cancer as they move beyond their disease and its treatment. By asking open-ended questions, the nurse can help women explore their experience so they can begin to shift their view of breast cancer from an experience of sickness and death to a surmountable challenge.
If a mass is found during pregnancy, ultrasound is the preferred diagnostic method because it involves no exposure to radiation, although mammography with appropriate shielding, fine-needle aspiration, and biopsy may also be indicated. Treatment is basically the same as in other women, although radiation is contraindicated in pregnancy. Some oncologists begin chemotherapy as early as the 16th week of pregnancy because fetal organs are already formed at this point. If systemic treatment is necessary, a cesarean section may be performed as soon as maturation of the fetus allows. If aggressive disease is detected early in pregnancy and chemotherapy is advised, termination of the pregnancy is an issue that some patients must face. If a mass is found while a woman is breastfeeding, she is urged to stop breastfeeding to allow the breast to involute (return to its baseline state) before any type of surgery is performed.
Chapter 48
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After a woman has completed treatment for breast cancer, she may consider having children. In this case, individual issues must be addressed, including the patient and her partner’s desire for children and family, disease and prognostic concerns, age, fertility and infertility issues, and social, financial, ethical, and quality-oflife issues. Although recommendations vary, most women are advised to wait 2 years before becoming pregnant after completing treatment for breast cancer. Most retrospective studies indicate that pregnancy after treatment for breast cancer does not appear to increase the risk of the disease recurring (Gemignani & Petrek, 1999); however, prospective studies are needed to confirm this. Counseling, providing accurate information, and active listening and caring are important nursing interventions when patients are involved in making difficult personal decisions about treatment options, childbearing, or termination of pregnancy.
NURSING PROCESS: THE PATIENT WITH BREAST CANCER Assessment The health history includes an assessment of the patient’s reaction to the diagnosis and her ability to cope with it. Pertinent questions include the following: • How is the patient responding to the diagnosis? • What coping mechanisms does she find most helpful? • What psychological or emotional supports does she have and use? • Is there a partner, family member, or friend available to assist her in making treatment choices? • What are the most important areas of information she needs? • Is the patient experiencing any discomfort?
Diagnosis PREOPERATIVE NURSING DIAGNOSES Based on the health history and other assessment data, the patient’s major preoperative nursing diagnoses may include the following: • Deficient knowledge about breast cancer and treatment options • Anxiety related to cancer diagnosis • Fear related to specific treatments, body image changes, or possible death • Risk for ineffective coping (individual or family) related to the diagnosis of breast cancer and related treatment options • Decisional conflict related to treatment options POSTOPERATIVE NURSING DIAGNOSES Based on the health history and other assessment data, the patient’s major postoperative nursing diagnoses may include the following:
• Acute pain related to surgical procedure • Impaired skin integrity due to surgical incision • Risk for infection related to surgical incision and presence of surgical drain
• Disturbed body image related to loss or alteration of the breast related to the surgical procedure
• Risk for impaired adjustment related to the diagnosis of cancer, surgical treatment, and fear of death
• Self-care deficit related to partial immobility of upper extremity on operative side
• Disturbed sensory perception (kinesthesia) related to sensations in affected arm, breast, or chest wall
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• Risk for sexual dysfunction related to loss of body part, change in self-image, and fear of partner’s responses
• Deficient knowledge: drain management after breast surgery • Deficient knowledge: arm exercises to regain mobility of affected extremity
• Deficient knowledge: hand and arm care after an axillary lymph node dissection
COLLABORATIVE PROBLEMS/ POTENTIAL COMPLICATIONS Based on the assessment data, potential complications may include the following: • Lymphedema • Hematoma formation • Infection
Planning and Goals The major goals for the patient may include increased knowledge about the disease and its treatment; reduction of preoperative and postoperative fears, anxiety, and emotional stress; improvement of decision-making ability; pain management; maintenance of skin integrity; improved self-concept; improved sexual function; and the absence of complications.
Preoperative Nursing Interventions EXPLAINING BREAST CANCER AND TREATMENT OPTIONS The patient confronting the diagnosis of breast cancer reacts with fear, dread, and anxiety. In view of the usually overwhelming emotional reactions to the diagnosis, the patient must be given time to absorb the significance of the diagnosis and any information that will help her to evaluate treatment options. The nurse caring for the woman who has just received a diagnosis of breast cancer needs to be knowledgeable about current treatment options and able to discuss them with the patient. The nurse should be aware of the information that has been given to the patient by the physician. Information about the surgery, the location and extent of the tumor, and postoperative treatments involving radiation therapy and chemotherapy are details that the patient needs to enable her to make informed decisions. As appropriate, the nurse discusses with the patient medications, the extent of treatment, management of side effects, possible reactions after treatment, frequency and duration of treatment, and treatment goals. Methods to compensate for physical changes related to mastectomy (eg, prostheses and plastic surgery) are also discussed and planned. The amount and timing of the information provided are based on the patient’s responses, coping ability, and readiness to learn. REDUCING FEAR AND ANXIETY AND IMPROVING COPING ABILITY The patient’s emotional preparation begins when the tentative diagnosis of cancer is made. Patients who have lost close relatives to breast cancer (or any cancer) may have difficulty coping with the possible diagnosis of breast cancer because memories of loss and death can emerge during their own crisis. The patient may have the diagnostic procedure performed in the surgeon’s office or in the hospital when she is admitted for ambulatory or same-day surgery for a biopsy. Fears and concerns are common and are discussed with the patient. If she will undergo a mastectomy, information about various resources and options is provided. Such services include prostheses, reconstructive surgery, and groups such as Reach to Recovery. Discussion with
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a plastic surgeon about the various options for reconstructive surgery can be a valuable source of information and support. The nurse provides anticipatory teaching and counseling at each stage of the process and identifies the sensations that can be expected during additional diagnostic procedures. The nurse also discusses the implications of each treatment option and how it may affect various aspects of the patient’s treatment course and lifestyle. The patient is introduced to other members of the oncology team (eg, radiation oncologist, medical oncologist, oncology nurse, and social worker) and is acquainted with the role of each in her care. After the treatment plan has been established, the nurse needs to promote preoperative physical, psychological, social, and nutritional well-being. The patient usually prefers to be active in her care and decision making. Some women find it helpful and reassuring to talk to a breast cancer survivor, someone who has completed treatment and has been trained as a volunteer to talk with newly diagnosed patients. PROMOTING DECISION-MAKING ABILITY At times, a patient may demonstrate behavior that indicates she cannot make a decision about treatment. Careful guidance and supportive counseling are the interventions the nurse can use to help such a patient. Also, encouraging the patient to take one step of the treatment process at a time can be helpful. The advanced practice nurse or oncology social worker can be helpful for patients and family members in discussing some of the personal issues that may arise in relation to treatment. Some patients may need a mental health consultation before surgery to assist them in coping with the diagnosis and impending treatment. Such patients may have had a history of psychiatric problems or demonstrate behavior that leads the surgeon or nurse to initiate a referral to the psychiatrist, psychologist, or psychiatric clinical nurse specialist.
Postoperative Nursing Interventions RELIEVING PAIN AND DISCOMFORT Ongoing nursing assessment of pain and discomfort is important because patients experience differing degrees of pain intensity. Some women may have more generalized pain and discomfort of the chest wall, affected breast, or affected arm. Moderate elevation of the involved extremity is one means of relieving pain because it decreases tension on the surgical incision, promotes circulation, and prevents venous congestion in the affected extremity. Intravenous or intramuscular opioid analgesic agents are another method to manage pain in the initial postoperative phase. After the patient is taking fluids and food and the anesthesia has cleared sufficiently (usually by the next morning), oral analgesic agents can be effective in relieving pain. Patient teaching before discharge then becomes important in managing discomfort after
surgery because pain intensity varies widely. Patients should be encouraged to take analgesic agents (opioid or nonopioid analgesic medications such as acetaminophen) before exercises or at bedtime and also to take a warm shower twice daily (usually allowed on the second postoperative day) to alleviate the discomfort that comes from referred muscle pain. MAINTAINING SKIN INTEGRITY AND PREVENTING INFECTION In the immediate postoperative period, the patient will have a snug but not tight dressing or a surgical bra packed with gauze over the surgical site and one or more drainage tubes in place. A particular concern is preventing fluid from accumulating under the chest wall incision or in the axilla by maintaining the patency of the surgical drains. The dressings and drains should be inspected for bleeding and the extent of drainage monitored regularly. If a hematoma develops, it usually occurs within the first 12 hours after surgery; thus, monitoring the incision is important. A hematoma could cause necrosis of the surgical flaps, although this complication is rare in breast surgery patients. If either of these complications occurs, the surgeon should be notified, and the patient should have an Ace wrap placed around the incision and an ice pack applied. Initially, the fluid in the surgical drain appears bloody, but it gradually changes to a serosanguinous and then a serous fluid during the next several days. The drain is usually left in place for 7 to 10 days and is then removed after the output is less than 30 mL in a 24-hour period. The patient is discharged home with the drains in place; therefore, teaching of the patient and family is important to ensure correct management of the drainage system (Chart 48-6). Dressing changes present an opportunity for the nurse and patient to discuss the incision, particularly how it looks and feels and the progressive changes in its appearance. The nurse explains the care of the incision, sensations to expect, and the possible signs and symptoms of an infection. Generally, the patient may shower on the second postoperative day and wash the incision and drain site with soap and water to prevent infection. A dry dressing should be applied to the incision each day for 7 days. The patient needs to know that sensation is decreased in the operative area because the nerves were disrupted during surgery and that gentle care is needed to avoid injury. After the incision is completely healed (usually 4 to 6 weeks), lotions or creams may be applied to the area to increase skin elasticity. After the incision is fully healed, the patient may again use deodorant on the affected side, although many women note that they no longer perspire as much as before the surgery. PROMOTING POSITIVE BODY IMAGE During teaching sessions, the nurse can address the patient’s perception of the body image changes and physical alteration of the
Chart 48-6 Home Care Checklist • Surgical Breast Cancer Patient with a Drainage Device At the completion of the home care instruction, the patient or caregiver will be able to: • Demonstrate how to empty and measure fluid from the drainage device • Demonstrate how to strip or milk clots through the tubing of the drainage device • State observations that require contacting the physician or nurse (eg, sudden drainage color change, sudden cessation of drainage, signs or symptoms of an infection) • Care for the drain site as per surgeon’s recommendation • Identify when the drain is ready for removal (usually when draining less than 30 mL for a 24-hour period)
Patient
Caregiver
✓ ✓
✓ ✓
✓ ✓ ✓
✓ ✓ ✓
Chapter 48
Assessment and Management of Patients With Breast Disorders
breast. Patients may initially be uncomfortable looking at the surgical incision. No matter how prepared a patient may be, the view of her incision and absence of her breast is often difficult for her. Exploring this sensitive area must be a careful nursing action, and cues provided by the patient must be respected and sensitively handled. Privacy is a consideration when assisting the woman to view her incision fully for the first time and allows the patient to express her feelings safely to the nurse. Asking the patient what she perceives, acknowledging her feelings, and allowing her to express her emotions are important nursing actions. Explaining that her feelings are a normal response to breast cancer surgery may be reassuring to the patient. Ideally, she will see the incision for the first time when she is with the nurse or another health care provider who is available for support. With short hospital stays, many women will view the incision for the first time with the home care nurse or ambulatory care nurse at the time of postoperative follow-up visits. PROMOTING POSITIVE ADJUSTMENT AND COPING Ongoing assessment of the patient’s concerns related to the diagnosis of cancer, the consequences of surgical treatment, and fear of death is important in determining her progress in adjusting and the effectiveness of her coping strategies. Assisting the patient in identifying and mobilizing her support systems is important. The patient’s spouse or partner may need guidance, support, and
Table 48-6
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education as well. The patient and spouse may benefit from a wide network of available community resources, including the American Cancer Society’s Reach to Recovery program, advocacy groups, or a spiritual advisor. Encouraging the patient to discuss issues and concerns with other patients who have had breast cancer may help her to understand that her feelings are normal and that other women who have had breast cancer can provide invaluable support and understanding. Another important aspect of promoting the patient’s adjustment and coping includes answering questions and addressing her concerns about the treatment options that may follow surgery. After the surgery has been completed, thoughts about what lies in the future in terms of additional treatment are normal, and this topic can cause understandable anxiety. Refocusing the patient on the recovery from surgery, while addressing her concerns and answering her questions, can be helpful. Being knowledgeable about the plan of care and encouraging the patient to ask questions of the appropriate members of the health care team will also promote coping during recovery. A few women require additional support to adjust to the diagnosis and the changes that it brings. If a woman displays ineffective coping, counseling or consultation with a mental health practitioner may be indicated. Table 48-6 summarizes the needs of and nursing interventions for patients and their partners at various stages of the breast can-
• Needs and Nursing Interventions for Patients and Partners
DIAGNOSTIC PHASE
POSTSURGICAL PHASE
Needs and Interventions Related to the Health Care System Minimize uncertainty: Establish confidence in health • correct misinformation care: • discuss surgical options • encourage questions • explore resources • provide information on • explain health care system postoperative care logistics • promote a sense of control Needs and Interventions Related to Physical Well-Being Promote physical well-being: Prevent disease advancement: • provide information on the • expedite early treatment healing process • reduce anxiety through • discuss self-care timely care Needs and Interventions Related to Psychological Well-Being Protect emotional well-being: Develop a framework of • alter perceptions of the illness expectations: • foster active participation in • describe the treatment health care process • identify ways to reduce • discuss potential emotional anxiety sequelae • support a positive self-image • help to accept altered roles Needs and Interventions Related to Social Support Establish trusting communication: Establish a supportive network: • explore the meaning of the • consider sources of diagnosis emotional support • examine treatment options • foster the ability to ask for help
ADJUVANT THERAPY PHASE
ONGOING RECOVERY PHASE
Develop a supportive network: • clarify information • discuss side effects and management • assist in decision making
Maintain association with professionals: • encourage regular followup exams, changes in diet and exercise • teach early detection skills • provide realistic reassurance
Minimize adverse physical outcomes: • promote recovery from surgery • teach side effects management
Maintain a positive outlook: • assess perception of physical change • encourage healthful behaviors
Manage stress: • identify feelings of vulnerability • provide information on adjuvant therapies and potential side effects • encourage communication of needs
Redefine self and partner: • normalize activities of daily living • reprioritize values, needs, and expectations • incorporate healthpromoting behaviors
Understand family members’ responses: • interpret others’ reactions
Cultivate ongoing support: • promote an understanding of how to live as a cancer survivor
Reproduced with permission from Hoskins, C. N., & Haber, J. (2000). Adjusting to breast cancer. American Journal of Nursing, 100(4), 26–32.
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cer experience. Chart 48-7 provides insights into ways to initiate conversations with patients and their partners in different phases of therapy. PROMOTING PARTICIPATION IN CARE Ambulation is encouraged when the patient is free of postanesthesia nausea and is tolerating fluids. The nurse supports the patient on the nonoperative side. Exercises (hand, shoulder, arm, and respiratory) are initiated on the second postoperative day, although instruction occurs on the first postoperative day. The goals of the exercise regimen are to increase circulation and muscle strength, prevent joint stiffness and contractures, and restore
Chart 48-7
Talking with Patients & Partners
For patients in the diagnostic phase: We’ve talked about your recent breast cancer diagnosis. It’s natural for you to be full of feelings, concerns, and fears about yourself and your family. Sometimes it’s hard to find someone to speak freely with. Would you share what you’ve been thinking, feeling, and worrying about recently? For partners in the diagnostic phase: We’ve talked about your partner’s recent breast cancer diagnosis. It’s natural for you to have a lot of feelings, concerns, and fears about your partner, yourself, and your family. Partners often feel that they have to be strong for the patient or for others and that they aren’t entitled to express their own concerns. Would you share what you’ve been thinking about, feeling, or worrying about recently? For patients in the postsurgical phase: Many women who have had breast surgery, especially mastectomy or extensive lumpectomy are concerned not only with their own loss, but with how their partner will accept it. How have you felt about losing [part of] your breast? How has it changed your body image? Your sense of your sexuality? Your desire for intimacy? For partners in the postsurgical phase: Many partners of women who have had breast surgery are concerned, as are the women themselves, about how they’ll respond to the loss. How have you felt about your partner’s losing [part of] her breast? How has it changed her attractiveness for you? Your sexual feelings toward her? Your desire for intimacy? For patients in the adjuvant therapy phase: Given the type of therapy (radiation, chemotherapy, hormone therapy) you’re going to have, what side effects do you anticipate? What do you know about them? Let’s talk about ways to reduce and handle potential side effects. For partners in the adjuvant therapy phase: Given the type of therapy (radiation, chemotherapy, hormone therapy) your partner is going to have, what side effects do you anticipate? What do you know about them? Let’s talk about ways to reduce and handle potential side effects, and how it might help you to be familiar with them. For patients in the ongoing recovery phase: As you plan your return to a full work schedule, what measures—setting priorities, delegating responsibility, managing stress—might help you make the necessary physical and emotional adjustments? What have you learned about balancing work, family, and play in your life? For partners in the ongoing recovery phase: As your partner plans her return to a full work-schedule, what strategies have you thought about using to make your own physical and emotional adjustments, so that you don’t continue to be overburdened at work and at home? Reproduced with permission from Hoskins, C. N., & Haber, J. (2000). Adjusting to breast cancer. American Journal of Nursing, 100(4), 26–32.
full range of motion. Hand exercises are also important for the same reasons. Postmastectomy exercises (Chart 48-8) are usually performed three times daily for 20 minutes at a time until full range of motion is restored (generally 4 to 6 weeks). Showering before exercising loosens stiff muscles, and taking an analgesic agent 30 minutes before beginning exercise increases the patient’s ability to comply with the regimen. Also, self-care activities, such as brushing the teeth, washing the face, and combing and brushing the hair, are physically and emotionally therapeutic because they aid in restoring arm function and a sense of normalcy for the patient. The nurse encourages the patient to use the muscles in both arms and to maintain proper posture. If a patient is favoring or splinting the affected side, or not standing up straight, any exercise will be ineffective. If a patient has skin grafts, a tense, tight surgical incision, or immediate reconstruction, exercises may need to be prescribed specifically and introduced gradually. Most patients find that after the drain is removed, range of motion returns quickly if they have been compliant with their exercise programs. This reinforcement may be provided in the outpatient setting by the ambulatory care nurse or the home care nurse. Patients are instructed regarding activity limitations while healing postoperatively. Generally, heavy lifting is avoided, although normal household and work-related activities are promoted to maintain muscle tone. Driving may begin after the drain is removed and when the patient has full range of motion and is no longer taking opioid analgesic agents. General guidelines for activity focus on gradually introducing previous activities (eg, bowling, weight-training) when fully healed, although checking with the physician beforehand is usually indicated. Transient edema in the affected extremity is common during the healing period, and women are encouraged to elevate the arm above the level of the heart on a pillow for 45 minutes at a time three times daily to promote circulation. Performing the prescribed exercises also assists in reducing the transient edema. Prevention of lymphedema is taught to patients before discharge. Hand and arm care after an axillary lymph node dissection focuses on the prevention of injury or trauma to the affected extremity, which increases the likelihood of developing lymphedema (Chart 48-9). MANAGING POSTOPERATIVE SENSATIONS Because nerves in the skin are cut during breast surgery, patients experience a variety of sensations. Common sensations are tightness, pulling, burning, and tingling along the chest wall, in the axilla, and along the inside aspect of the upper arm. They tend to become more noticeable and increase as the patient begins to heal. They usually persist for several months up to a year and then begin to diminish. Explaining to the patient that this is a normal part of healing helps to reassure her that these sensations are not indicative of a problem. Performing the exercises may decrease the sensations. Acetaminophen (Tylenol), taken as needed, also assists in managing the discomfort. Many breast surgery patients report these sensations as one of the most bothersome aspects of having the surgery. IMPROVING SEXUAL FUNCTION Most breast surgery patients are physically allowed to engage in sexual activity once discharged from the hospital. However, any change in the patient’s body image and self-esteem or the partner’s response may increase the couple’s anxiety level and may affect sexual function. Some partners may have difficulty looking at the incision, whereas others appear to be unaffected and com-
Chapter 48
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Chart 48-8
• PATIENT EDUCATION Exercises After Breast Surgery
1. Wall handclimbing. Stand facing the wall with feet apart and toes as close to the wall as possible. With elbows slightly bent, place the palms of the hand on the wall at shoulder level. By flexing the fingers, work the hands up the wall until arms are fully extended. Then reverse the process, working the hands down to the starting point.
3. Rod or broomstick lifting. Grasp a rod with both hands, held about 2 feet apart. Keeping the arms straight, raise the rod over the head. Bend elbows to lower the rod behind the head. Reverse maneuver, raising the rod above the head, then return to the starting position.
2. Rope turning. Tie a light rope to a doorknob. Stand facing the door. Take the free end of the rope in the hand on the side of surgery. Place the other hand on the hip. With the rope-holding arm extended and held away from the body (nearly parallel with the floor), turn the rope, making as wide swings as possible. Begin slowly at first; speed up later.
4. Pulley tugging. Toss a light rope over a shower curtain rod or doorway curtain rod. Stand as nearly under the rope as possible. Grasp an end in each hand. Extend the arms straight and away from the body. Pull the left arm up by tugging down with the right arm, then the right arm up and the left down in a see-sawing motion.
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Chart 48-9
• PATIENT EDUCATION Hand and Arm Care After Axillary Dissection • Avoid blood pressures, injections, and blood draws in affected extremity.
• Use sunscreen (higher than 15 SPF) for extended exposure to sun. Apply insect repellent to avoid bug bites. Wear gloves for gardening. Use cooking mitt for removing objects from oven. Avoid cutting cuticles; push them back during manicures. Use electric razor for shaving armpit. Avoid lifting objects greater than 5–10 pounds. If a trauma or break in the skin occurs, wash the area with soap and water, and apply an over-the-counter antibacterial ointment (Bacitracin or Neosporin). • Observe the area and extremity for 24 hours; if redness, swelling, or a fever occurs, call the surgeon or nurse.
• • • • • • •
fortable. Either response affects the patient’s self-image, sexuality, and acceptance. Open discussion and clear communication about how the patient sees herself and about possible decreased libido related to fatigue, anxiety, or nausea may help to clarify issues for her and her partner. Encouraging discussion about fears, needs, and desires may reduce the couple’s stress. Suggestions regarding varying the time of day for sexual activity (when the patient is less tired) or assuming positions that are more comfortable can be helpful, as are other options for expressing affection (eg, hugging, kissing, manual stimulation). Most patients and their partners adjust with minimal difficulty if they openly discuss their concerns; however, if problems develop or persist, referral to a psychosocial resource (psychologist, psychiatrist, or psychiatric clinical nurse specialist, social worker, or sex therapist) can be helpful for the woman and her partner. To identify difficulty in sexual relationships, the ambulatory care nurse and home care nurse must be sensitive to this issue following treatment for breast cancer and must initiate discussion with the patient. MONITORING AND MANAGING POTENTIAL COMPLICATIONS Lymphedema Lymphedema can occur any time after an axillary lymph node dissection. Lymphedema results if functioning lymphatic channels are inadequate to ensure a return flow of lymph fluid to the general circulation. After removal of axillary nodes, collateral or auxiliary circulation must take over their function. Transient edema in the postoperative period occurs until this collateral circulation has fully assumed functioning for the removed nodes, which generally occurs within a month by moving and exercising the affected arm. Patients need reassurance that this transient swelling is not lymphedema. Education about how to prevent lymphedema is an important part of hand and arm care after an axillary dissection. Lymphedema occurs in about 10% to 20% of patients who undergo an axillary dissection. Risk factors for lymphedema are increasing age, obesity, presence of extensive axillary disease, radiation treatment, and injury or infection to the extremity. Patients should follow these guidelines to prevent injury to the affected extremity because lymphedema is subsequently associated with a trauma of some type.
If lymphedema occurs, the patient should contact the surgeon or nurse to discuss management because she may need a course of antibiotics or specific exercises to decrease the swelling. Emphasis should be placed on early intervention because lymphedema can be manageable if treated early; however, if allowed to progress without treatment, the swelling can become painful and difficult to reverse. Management consists of arm elevation with the elbow above the shoulder and the hand higher than the elbow, along with specific exercises, such as hand pumps. A referral to a physical therapist or rehabilitation specialist may be necessary for a custom-made elastic sleeve, exercises, manual lymph drainage, or a special pump to decrease swelling. Hematoma Formation Hematoma formation may occur after either mastectomy or breast conservation. The nurse monitors the surgical site for excessive swelling and monitors the drainage device, if present. Gross swelling or output from the drain may indicate hematoma formation, and the surgeon should be notified promptly. Depending on the surgeon’s assessment, an Ace wrap may be applied for compression of the surgical site along with ice packs for 24 hours, or the patient may be returned to surgery to identify the source of bleeding. The nurse monitors the site and reassures the patient that this complication is rare but does occur and that she will be assisted through its management. A calm demeanor on the part of the nurse helps prevent anxiety and panic on the part of the patient. Infection Infection follows breast surgery in about 1 in 100 patients. Infection can occur for a variety of reasons, including concurrent conditions (diabetes, immune disorders, advanced age) and exposure to pathogens. In addition, cellulitis may occur after breast surgery. Both preoperatively and before discharge, patients are taught to monitor for signs and symptoms of infection (redness, foul-smelling drainage, temperature greater than 100.4°F) and to contact the surgeon or nurse for evaluation. Treatment consists of oral or intravenous antibiotics for 1 or 2 weeks, depending on the severity of the infection. Cultures are taken of any foul-smelling discharge. Infections are a serious threat to women who have had breast reconstruction because they may lose the breast mound if the infection persists; there is a risk of lymphedema in women who develop an infection and have had an axillary lymph node dissection. PROMOTING HOME AND COMMUNITY-BASED CARE Teaching Patients Self-Care Patients who undergo breast surgery receive a tremendous amount of information before and after surgery. Additional teaching is necessary to prepare the patient and family to manage aspects of care after home discharge. Even though the ambulatory care nurse prepares the patient for what to expect postoperatively, the details often appear less important to the patient in light of the diagnosis of breast cancer. Thus, teaching may need to be repeated and reinforced postoperatively. Most patients are discharged 1 or 2 days after the surgery with the drains in place. The inpatient nurse assesses the patient’s readiness to assume self-care and focuses on teaching the patient incision care; signs to report, such as an infection; pain management; arm exercises; hand and arm care; and management of the drainage system at home. Family members may be included in the discharge teaching, and many women find it reassuring and helpful to have another person assist them with
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management of the drainage system. The ambulatory care nurse reinforces teaching by telephone follow-up and during postoperative visits in the office. Continuing Care Referral for home care may be indicated to assist the patient and family caregiver with postoperative care at home. The home care nurse assesses the patient’s incision and drainage system, physical and psychological status, adequacy of pain management, and adherence to the exercise plan. In addition, the home care nurse reinforces previous teaching and communicates important physiologic findings or psychosocial issues to the patient’s primary care provider, nurse, or surgeon. Follow-up visits to the physician after diagnosis and treatment of breast cancer depend on the individual and on postoperative treatments, stage of disease at diagnosis, late effects from cancer, and the patient’s adaptation. Visits every 3 months for 2 years, followed by every 6 months up to 5 years, may be then extended to annual examinations, depending on the patient’s progress and the physician’s preference. A disease-free state for as long as possible is the goal. Patients are also encouraged to do BSE on the remaining breast (and operative side if breast-conserving surgery was done) and the chest wall (after mastectomy) between appointments because the risk for cancer in the remaining breast (or recurrence in the operative breast) is about 1% per year after the original diagnosis. Additional screening is done with annual mammography. Ultrasound and MRI are being used more commonly with women who have survived breast cancer. Because it is common to ignore routine health care when a major health issue arises, the woman is reminded of the importance of participating in health promotion activities and other health screening. Because some problems with coping may not occur until the woman has returned to more usual routines, the ambulatory care nurse needs to be sensitive to this issue and encourage discussion throughout the recovery period.
Evaluation EXPECTED PREOPERATIVE PATIENT OUTCOMES Expected preoperative patient outcomes may include: 1. Exhibits knowledge about diagnosis and treatment options a. Asks relevant questions about diagnosis and available treatments b. States rationale for surgery and other treatment options c. Describes advantages and disadvantages of treatment options 2. Verbalizes willingness to deal with anxiety and fears related to the diagnosis and the effects of surgery on selfimage and sexual functioning 3. Demonstrates ability to cope with diagnosis and treatment a. Verbalizes feelings appropriately and recognizes normalcy of mood lability b. Proceeds with treatment in timely fashion c. Discusses impact of diagnosis and treatment on family and work 4. Demonstrates ability to make decisions regarding treatment options in timely fashion EXPECTED POSTOPERATIVE PATIENT OUTCOMES Expected postoperative patient outcomes may include: 1. Reports that pain has decreased and states pain and discomfort management strategies are effective
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2. Exhibits clean, dry, and intact surgical incisions without signs of inflammation or infection 3. Lists the signs and symptoms of infection to be reported to the nurse or surgeon 4. Verbalizes feelings regarding change in body image 5. Discusses meaning of the diagnosis, surgical treatment, and fears (especially of death) appropriately 6. Participates actively in self-care activities a. Performs exercises as prescribed b. Participates in self-care activities as prescribed 7. Recognizes that postoperative sensations are normal and identifies management strategies 8. Discusses issues of sexuality and resumption of sexual relations 9. Demonstrates knowledge of postdischarge recommendations and restrictions a. Describes follow-up care and activities b. Demonstrates appropriate care of incisions and drainage system c. Demonstrates arm exercises and describes exercise regimen and activity limitations during postoperative period d. Describes care of affected arm and hand and lists indications to contact the surgeon or nurse 10. Experiences no complications a. Identifies signs and symptoms of reportable complications (ie, redness, heat, pain, edema) b. Describes side effects of chemotherapy and strategies to cope with possible side effects c. Explains how to contact appropriate health care providers in case of complications Care of the patient with breast cancer is summarized in the Plan of Nursing Care.
RECURRENT BREAST CANCER The recurrence of breast cancer can be very difficult for patients and family members. Depending on the clinical presentation, progression of the disease can have different meanings. Generally, the longer the disease-free interval, the better the prognosis. Local recurrence either in the affected breast or along the chest wall can be treated, generally with surgery, radiation, or hormonal manipulation, although a metastatic disease workup may be in order to look for further evidence of disease. Although metastatic spread of the breast cancer (to the bone, lungs, brain, or liver) cannot be cured, a variety of treatments are available (chemotherapy, radiation treatment, hormonal manipulation, or possibly some form of surgery). In some patients, metastases progress very slowly and life functioning is generally not affected, whereas in others the disease progresses rapidly despite treatment, and death from the complications of metastatic disease is inevitable. The patient with advanced breast cancer is monitored closely for signs that the tumor has recurred or that metastasis has occurred. The following studies are conducted to monitor for spread of disease: metastatic x-ray series (chest, skull, long bones, and pelvis); liver function tests (alkaline phosphatase, aspartate aminotransferase [AST] or serum glutamic-pyruvic transaminase [ALT] lactate dehydrogenase); mammogram of contralateral breast and ipsilateral breast (if breast-conserving surgery was originally performed); and bone, liver, and brain imaging. In half of all patients with recurrent disease, the cancer reappears locally (on the chest wall or in the conserved breast) or regionally in the remaining (text continues on page 1478)
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Plan of Nursing Care Care of the Patient With Breast Cancer Nursing Interventions
Rationale
Expected Outcomes
Nursing Diagnosis: Fear and ineffective coping related to the diagnosis of breast cancer, its treatment, and prognosis Goal: Reduction of emotional stress, fear, and anxiety 1. Begin emotional preparation of the patient (and partner) as soon as she is informed of tentative diagnosis. 2. Assess: a. Personal experience with and knowledge about breast cancer b. Coping mechanisms in crisis c. Support systems d. Emotional reaction to diagnosis 3. Inform the patient of recent research and new treatment modalities for breast cancer. 4. Describe the experiences the patient will face and encourage her questions. 5. Acquaint her with available resources to facilitate her recovery.
1. This enables the patient to initiate coping responses.
• Displays reduced emotional stress and
2. These factors strongly affect the patient’s behavior and ability to deal with the diagnosis, surgery, and follow-up treatment. If a patient has lost close relatives or friends to breast cancer, she will probably react differently from a patient who has friends surviving with an excellent quality of life. 3. Increasing options and improved results both statistically and cosmetically greatly reduce the fear and promote acceptance of the treatment plan. 4. Decreases fear of the unknown.
•
5. The information about new prosthetics, reconstruction specialists, and other resources confirms that a great deal of attention is being given to newer treatment methods for breast cancer.
• • •
• •
anxiety and exhibits an ability to cope with the problem Participates in the treatment plan and asks questions relating to the best choice for her particular needs States that anger, anxiety, depression, denial, and withdrawal are normal reactions Responds positively to the information she has received Describes the value of social support of family, friends, and women who have had breast surgery in coping with a stressful experience Is aware that partner has been advised and prepared with regard to supportive role Reads literature provided
Nursing Diagnosis: Disturbed body image related to nature of surgery and side effects of radiation and/or chemotherapy Goal: Realistic adaptation to changes that will occur relative to treatment modalities 1. Confirm with the physician the nature of the treatment anticipated. 2. Explain that it is normal to experience grief at the loss of a body part. 3. Encourage visits by loved ones and understanding friends. 4. Explain that it is normal not to want herself or partner to view the incision (do not refer to this as a “scar”); further reinforce the fact that each day the site will look better. 5. Discuss the use of prosthesis, reconstruction possibilities, and clothing adjustment as realistic and attainable expectations.
1. This sets the basis for a cooperative therapeutic plan that will prevent conflicting information from reaching the patient. 2. With this understanding, the patient can then be free to move to the next level of coping. 3. Support systems that are meaningful to the patient are more endurable than those from relative strangers. 4. This reduces the feeling that she will never be able to adjust to her altered body.
• Decides on the treatment plan after discussion with physician and family
• Verbalizes that grief must run its course • Uses her support system effectively; plans future activities with them
• Eventually looks at her incision site and participates in dressing changes
• Expresses an understanding of the long-
term benefits of chemotherapy/radiation (if prescribed) even though there may be uncomfortable side effects
5. The emphasis on the positive and the availability of adaptations will enhance her self-concept and promote positive acceptance of the treatment plan.
Nursing Diagnosis: Acute pain related to tissue trauma from incision(s) Goal: Absence of pain and discomfort 1. Assess intensity, nature, and location of pain. 2. Administer analgesia by IM, oral, or IV route as prescribed.
1. Provides baseline to assess effectiveness of pain relief measures 2. Promotes pain relief
• Reports when pain is worsening and accepts prescribed pain medication
• Adjusts her position to relieve discomfort; uses small pillows effectively
(continued)
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Plan of Nursing Care Care of the Patient With Breast Cancer (Continued) Nursing Interventions 3. Collaborate with physician about use of patient-controlled analgesia (PCA). 4. Explain that analgesics are available for pain relief. 5. Proper body positioning will promote comfort, such as semi-Fowler’s position and elevation of the arm of the affected side. 6. Promote passive and then active exercises of the hand, arm, and shoulder of the affected side. 7. Encourage protection and the avoidance of anything that can break through the skin barrier to impose stress on the arm and shoulder (cuts, burns, strong detergents, infections, carrying a heavy bag or purse). 8. Suggest application of an effective cream several times a day. 9. Instruct patient to contact the physician if the arm or incision site becomes painful, swollen, or red. 10. Suggest wearing a medical identification tag if there is a potential for injury or edema.
Rationale 3. Patient-controlled analgesia results in pain relief and increased comfort and maintains patient’s sense of control. 4. Analgesics and opioids can interrupt nerve pathways to the brain and spinal cord. 5. Stress on the incision site is reduced; gravity reduces fluid accumulation in the arm. (Squeezing ball and wrist flexion begin in first 24 hours.) 6. This will stimulate circulation, promote neurovascular competence, and prevent stasis and subsequent stiffening of the shoulder girdle. 7. Impaired circulation and weakened muscles are vulnerable to sudden or prolonged stress.
Expected Outcomes • Exercises frequently; moves affected arm • • •
gently and shows progress in moving from passive to active exercises Describes home-related activities that will provide the required range of motion of the affected arm Relates procedures to follow if injury is sustained Orders medical identification tags when arm lymphedema is diagnosed
8. This practice will keep the skin healthy, intact, pliable, and resistant to breakdown. 9. Early treatment of possible infection or injury will avoid further discomfort and complications. 10. A recognized medical identification tag will serve as a precaution against injury to the affected arm.
Nursing Diagnosis: Dressing/grooming, bathing/hygiene self-care deficit related to partial immobility of upper extremity on side of breast surgery Goal: Avoidance of impaired mobility and achievement of self-care to the fullest possible level 1. Encourage patient’s active participation in postoperative care. 2. Encourage patient’s socialization, particularly with others who have successfully recovered in similar circumstances. 3. Make progressive modifications in the patient’s exercise program as dictated by comfort and tolerance levels. 4. Provide positive reinforcement when ingenuity and creativity are in evidence, such as an attractive hairstyle or make-up application.
1. Patient involvement enhances and facilitates the recovery process. 2. Humans thrive more effectively when they are able to relate to others socially. 3. There is lessened strain on tissues; improvement is consistent. 4. Psychological well-being complements the effects of optimal physical good health.
• Participates in dressing change; expresses • • •
interest in working with rehabilitative team, including physical therapist Expresses concern about her appearance and accepts suggestions from rehabilitation support groups Participates in self-care (ie, dressing, bathing, grooming) Verbalizes anticipation and enjoyment of partner’s visits and relates her progress
Nursing Diagnosis: Possible sexual dysfunction related to loss of body part and fear of partner’s reaction to this loss Goal: Identification of alternative satisfying/acceptable sexual experiences 1. Become comfortable in discussing sexuality; display a caring, nonjudgmental, supportive attitude.
1. The patient will easily sense insincerity, insecurity, lack of knowledge, and inexperience. Nurses new to this area can obtain assistance from the oncology clinical nurse specialist.
• Responds by conveying trust and a desire •
to obtain assistance; asks appropriate questions. Includes partner in discussion of issues that concern both.
(continued)
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Plan of Nursing Care Care of the Patient With Breast Cancer (Continued) Nursing Interventions 2. Encourage, at the appropriate time, both partners to discuss their concerns; this can be done before and after major treatment. 3. Arrange for privacy when discussing personal issues with the patient. 4. Describe the incision site and its appearance to the partner before partner actually sees it. 5. Emphasize that behavioral changes take time and should not be interpreted as rejection.
Rationale
Expected Outcomes
2. The patient will not feel that she is alone in facing issues that may concern both partners. 3. Sensitive personal issues are not revealed when people not close to the patient are present. 4. Partner will know what to expect and not likely register shock in front of the patient. 5. Undergoing any surgery takes time for acceptance, recuperation, and perhaps altered lifestyle.
• Verbalizes concerns about sexuality issues • Accepts the incision site as evidenced by
•
assisting with dressings and using an appropriate prescribed emollient such as cocoa butter Expresses awareness that any adjustments take time but that with patience and understanding, the desired goals can be approached and possibly reached
Collaborative Problem: Infection, injury, lymphedema, neurovascular deficits Goal: Avoidance of complications 1. Encourage elevation of the arm, if not contraindicated, with each joint positioned higher than the more proximal joint. 2. Instruct patient to avoid injury, strenuous activity, or infection. 3. Describe and demonstrate exercises in a step-up fashion from simple to more complex. 4. Recommend physical therapy and a weight-reduction program if indicated.
1. Edema is reduced and there is less pressure on the nerves and blood vessels; pain and discomfort are reduced.
• Demonstrates positioning pillows so that
2. These can produce fluid accumulation and compromise the neurovasculature of the arm. 3. A graduated exercise program will improve muscle tone and hasten full range of activities with avoidance of impairment, such as a frozen shoulder. 4. Properly prescribed activities and exercise plus diet modification are general health measures that enhance well-being and reduce risk for complications.
• Gradually moves the arm freely so that
proper elevation of arm is maintained
• Describes strategies for avoiding injury and infection
lymph nodes, and in one fourth other organs become involved. Bone metastasis is the most common site for spread of the disease, usually involving the hips, spine, ribs, or pelvis. Other sites for metastatic spread are the brain, lungs, and liver.
Medical Management Regression or relief of the symptoms is the goal of nursing and medical management, and quality of survival time is an important focus of nursing intervention. Assessing the patient’s physical and psychosocial status is a challenge for the nurse. Information from family members and significant others is valuable and should be included in planning care for the patient with advanced disease. Palliative treatment, if indicated, is also an important aspect of care. Comfort and a pain-free existence, even if the disease cannot be eradicated, enhance the quality of remaining life. Palliative surgery may be offered if the patient has a fungating or necrotic tumor in the breast; the most common procedure is a modified radical mastectomy. In patients with bone metastases that cause pain or produce pathologic fractures, reparative or restorative surgery may also be an option; however, this may not
•
hair combing and “climbing the wall” can be achieved with no discomfort. Avoids the discomfort of a frozen shoulder. Acquires good health habits and avoids complications
be indicated depending on the patient’s medical status and personal choices. Hospice and home health care may be indicated as alternatives. Regardless, specific arrangements for these services should be discussed and planned early, before the actual need arises, to decrease patient distress. Severe anxiety and depression may occur. Treatment modes vary and depend on the patient’s condition, the modalities available, and the patient’s preferences for end-of-life care. Chapter 16 provides more information on the general care of the patient with advanced cancer. Chapter 17 discusses end-of-life care.
Reconstructive Breast Surgery Because the breast plays such an important part in self-image of many women, a perceived abnormality may lead to a request for mammoplasty (plastic surgery of the breast in which size, shape, or position is altered). Variations in the size of the breasts are a common reason for women to seek information about reconstructive breast surgery. Reduction mammoplasty is performed to reduce the size of the breast, whereas augmentation mammoplasty is performed to increase the size of the breast. Other women
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Assessment and Management of Patients With Breast Disorders
desire surgery to reconstruct their breasts after mastectomy. There are several different procedures used for this type of reconstructive surgery. In addition, some women choose to undergo prophylactic (risk-reducing) mastectomy if they are at high risk for breast cancer. This type of mastectomy is included in this discussion because it is considered elective.
REDUCTION MAMMOPLASTY Reduction mammoplasty is usually performed on women who have breast hypertrophy (excessively large breasts). If the enlargement occurs early in life, it is called virginal breast hypertrophy. The condition is usually bilateral but may affect just one breast. Hypertrophy in later life almost always affects both breasts. Tenderness, diffuse pain, and fatigue are common complaints of women with hypertrophy. Premenstrual tenderness and pain are marked. The weight of the enlarged breasts causes a dragging sensation in the shoulder, and support is commonly futile, despite use of the most supportive bra. Many women have deep grooves in their shoulders from the weight borne by bra straps. Poor posture, discomfort, and embarrassment when wearing bathing suits and participating in athletic events may limit the woman’s social life. As a result, insecurity may develop from poor self-image. After a surgical or plastic surgery consultation, a reduction mammoplasty may be performed under general anesthesia. One approach is an incision in the skin of the anterior breast in the shape of a keyhole or an anchor if a large amount of tissue needs to be removed. Another approach is through an incision around the areola complex. The surgeon then removes the excess tissue and transplants the nipple to a new location. Skin edges are approximated with sutures, and the nipple is secured with sutures. Drains are placed in the incision, where they remain for 1 to 2 days. Simple gauze dressings are applied, without pressure.
Postoperative Nursing Management After mammoplasty, the usual postoperative care is indicated. Patients are ambulatory fairly quickly and typically describe their surgery as nontraumatic, possibly because of the relief they experience. Hypertrophy does not recur, but if the patient gains weight, the breasts may enlarge. The newly transplanted nipple most likely becomes covered with a scab. As the nipple regains a new blood supply, the scab falls off, and the appearance approximates normal. Lactation may be impossible after this type of surgery, although half of women who have this surgery can breastfeed successfully. Sensory changes, such as numbness, are normal after this surgery but resolve after several months, although diminished sensation in the nipples can persist. Postoperatively, the woman may feel a mixture of euphoria, relief, sorrow over loss of a body part, and anxiety over these feelings. Providing reassurance is an important nursing measure.
AUGMENTATION MAMMOPLASTY Augmentation mammoplasty is requested frequently by women desiring larger or fuller breasts. It is performed through an incision along the undermargin of the breast, in the axilla, or at the border of the areola. The breast is then elevated, and a pocket is formed between the breast and the chest wall into which various types of synthetic materials are inserted to enlarge and uplift the breast. The subpectoral approach is preferred because it interferes less with clinical breast examinations or mammography than do subglandular implants. These procedures may be performed on an outpatient basis with local anesthesia. Infection, an immedi-
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ate complication that can occur, may require removal of the implant. A delayed complication, which usually occurs years after the surgery, is a capsular contracture (scar formation around the implant); further surgery may be needed to correct this problem. Saline implants are typically used for augmentation mammography. Silicone implants were used in the past; however, because of the reported systemic complications associated with their use, they have been removed from the market. They are now available only to women enrolled in controlled clinical trials designed to study specific safety questions. Long-term risks associated with their use are also being studied. Women with breast implants need to be aware that accurate mammograms are more difficult, and they should seek radiologists at specialized breast centers who are familiar with reading mammograms of women who have breast implants.
RECONSTRUCTIVE PROCEDURES AFTER MASTECTOMY When a woman undergoes a mastectomy (either total or modified radical) for the treatment of breast cancer, she may desire to have immediate reconstruction at the time of surgery, or delayed reconstruction may be an option at a later point after all treatments have been completed. About 75% of women with breast cancer undergoing mastectomy elect immediate reconstruction. A consultation with the surgeon may assist women in deciding whether reconstruction is something that they desire at the time of surgery. It is important for women to understand that reconstruction does not interfere with the treatment of their breast cancer, and they should also understand that although a good cosmetic result can be obtained, the reconstructed breast will never be what they once had. Another key point for women to understand is that reconstruction is a three-stage process that occurs over a period of months: the first is creation of the breast mound, the second is achieving symmetry with the contralateral breast, and the third is creation of the nipple–areola complex (described later). Women who undergo reconstruction with realistic expectations tend to be more pleased with the cosmetic result. Also, women who have mastectomy with immediate reconstruction may demonstrate a more positive adjustment afterward. The choice of the surgical procedure is based on the patient’s wishes, the condition of the overlying skin and underlying muscle, and any previous scars that may be present, because they may limit possible reconstructive options. Another important factor is any secondary medical conditions that may affect the healing process (eg, hypertension, diabetes mellitus, tobacco use, or obesity).
Tissue Expanders With Permanent Implants One method of reconstruction is the tissue expander with permanent implant (Fig. 48-7). After the surgeon has completed the mastectomy, the plastic surgeon creates a pocket inside the pectoralis muscle and inserts a partially filled Silastic expander and a drainage device. Then, over a period of weeks, the patient comes to the office for injections of additional saline into the expander through a port that is under the skin; this temporary expander stretches the skin and muscle. When the implant is fully expanded (usually one third larger than the other breast to create a natural crease and droop to match the contralateral breast), the patient has the temporary implant exchanged for a permanent implant. This is usually performed as outpatient surgery. It may be done 4 to 6 months later to allow the tissue to soften and become more pliable before the permanent implant is inserted.
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FIGURE 48-7
A
B
C
Postoperative care is similar to that of the patient undergoing breast surgery, although more discomfort can be expected due to the additional surgery. Nausea may take longer to clear because there was a greater period under general anesthesia. Patients receive instruction just as any other surgical breast cancer patient would, but usually they are not allowed to shower until the drain is removed.
Tissue Transfer Procedures Another method of reconstruction is using the patient’s own tissue and transferring it to the mastectomy site. These flap surgeries can use the transverse rectus abdominis myocutaneous flap (TRAM flap) (Fig. 48-8), gluteal muscle, or latissimus dorsi muscle (Fig. 48-9). The plastic surgeon transfers the muscle flap with attached circulatory structures, skin, and fatty tissue, rotates it to the operative site, and molds it to create a mound that simulates
Breast reconstruction with tissue expander. (A) After mastectomy, a tissue expander is inserted to prepare for reconstruction. (B) The expander is gradually filled with saline solution through a tube to stretch the skin enough to accept an implant beneath the chest muscle. (C) The breast mound is restored. Although permanent, scars will fade with time. The nipple and areola are reconstructed later. Adapted from “Breast Reconstruction,” American Society of Plastic and Reconstructive Surgeons, Arlington Heights, IL.
the breast. These procedures are far more extensive and involve greater operative time (about 8 to 10 hours total time for the mastectomy and reconstruction) and duration of general anesthesia than does the tissue expander procedure. The risk for potential complications is greater (infection, bleeding, flap necrosis), but the benefits are a more natural-looking breast and avoidance of synthetic material. The recovery period is greater, and activity restrictions are different due to the cut muscles. The TRAM flap is the most commonly used tissue transfer procedure, and postoperative care involves drain management and monitoring the operative site for changes in circulation. During the immediate postoperative period, patients are more limited in their activity and are at greater risk for respiratory complications, so pulmonary hygiene is essential. Measures to reduce tension on the incisions include elevating the head of the bed by 30 degrees and flexing the patient’s knees to reduce tension on the abdominal incision. Antiemetic agents are administered to control nausea and vomiting, and analgesic medications are administered to reduce pain and discomfort. Assessing circulation by observing the color and temperature of the newly constructed breast area is an important nursing function. Mottling or an obvious decrease in skin temperature is reported to the surgeon immediately. Excessive drainage should also be reported. During ambulation, the patient usually protects the surgical incision by splinting. Gradually, she will achieve a more upright position. The patient is instructed to avoid tight and underwire bras until the surgeon indicates that no injury will result. Elevating the arms above the shoulder and lifting more than 5 pounds of weight are avoided for 1 month after surgery to avoid stress on the incision.
Nipple–Areola Reconstruction
A
B
FIGURE 48-8 Breast reconstruction: TRAM flap. (A) The flap of the transrectus abdominal muscle is tunneled through the abdomen to the breast area. In some cases a breast implant may not be needed if enough skin and muscle can be transferred. (B) Scarring will fade substantially over time. Adapted from “Breast Reconstruction,” American Society of Plastic and Reconstructive Surgeons, Arlington Heights, IL.
After the breast mound has been created and the site has healed, some women choose to have a nipple–areola reconstruction. This consists of minor surgical procedures carried out either in the physician’s office or as outpatient surgery. A nipple is created using a skin graft from the inner thigh or labia because this skin has darker pigmentation than the skin on the reconstructed breast. After the nipple graft has healed, the areolar complex is usually completed with micropigmentation (tattooing). The surgeon can usually match the reconstructed nipple–areola complex with that of the contralateral breast for an acceptable cosmetic result.
Chapter 48
Assessment and Management of Patients With Breast Disorders
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FIGURE 48-9
Breast reconstruction: latissimus dorsi flap. (A) Tissue taken from the back is tunneled to the front of the chest wall to support the reconstructed breast. (B) The transported tissue forms a flap that can hold a breast implant if there is not enough tissue to form a breast mound, or (C) tissue may be taken from the abdomen and tunneled to the breast or surgically transplanted to form a new breast mound. Adapted from “Breast Reconstruction,” American Society of Plastic and Reconstructive Surgeons, Arlington Heights, IL.
A
Diseases of the Male Breast GYNECOMASTIA Gynecomastia, or overdeveloped breast tissue, is the most common breast condition in the male. Adolescent boys can be affected by this condition because of hormones secreted by the testes. Gynecomastia usually subsides in 1 or 2 years, but it can occur before or after puberty and in elderly men. It is usually unilateral and presents as a firm, tender mass underneath the areola. In adult men, gynecomastia may be diffuse and related to medications (ie, digitalis, reserpine, ergotamine, ranitidine, and phenytoin). Pain and tenderness are initial symptoms. Treatment depends on the man’s feelings and preference. Observation is acceptable because it may resolve on its own; surgical removal of the tissue through an incision around the areola is another option. Liposuction of the tissue done by a plastic surgeon, another option, yields a positive cosmetic result.
MALE BREAST CANCER Cancer of the male breast accounts for 1% of all breast cancers; about 1,500 new cases of breast cancer and 400 deaths due to breast cancer occur annually (ACS, 2002b). Symptoms can include a painless lump beneath the areola, nipple retraction, nipple discharge, or skin ulceration. Diagnostic tests and treatment modalities are similar to those used for women. The average age of the patient at the time of diagnosis is 60 years, but it can occur in younger men, especially if there is a genetic link to the disease, because there may be a relationship to BRCA-2 in men with breast cancer. Risk factors may include a history of mumps orchitis, radiation exposure, and Klinefelter’s syndrome (a chromosomal condition reflecting decreased testosterone levels). Detection usually occurs well into the disease because cancer of the breast is not a common concern among men. Therefore, treatment generally consists of a modified radical mastectomy. If the pectoralis muscles are involved, a radical mastectomy is indicated. Radiation therapy may be used postoperatively. Prognosis varies depending on the stage of disease at diagnosis. Bone and soft tissue are the most common sites of advanced disease and metastasis. Orchiectomy (removal of the testes), adrenalectomy (removal of the adrenal gland), and hypophysectomy (removal of
B
C
the pituitary gland) may be used in advanced disease, but antihormonal agents are preferable because they are less invasive and disfiguring.
?
Critical Thinking Exercises
1.
You are caring for a patient who had breast augmentation surgery 10 years ago. When you ask her how often she examines her breasts, she states that she does not do so because she would be unable to detect masses because of her previous surgery. She also states that she does not think it is appropriate to touch her own breasts and that her physician performs a clinical breast examination each year when she has a Pap smear. How would you address the issues she has raised? Describe the teaching approach you would use.
2.
Your 40-year-old patient has been diagnosed with breast cancer. Her mother, aunt, and one of her sisters have all had breast cancer. She is very worried about her two daughters’ risks for breast cancer and asks if they should undergo genetic testing. She also asks about the need for her daughters to have mammograms performed. What guidelines would you give to this patient about mammography and genetic testing that might be considered for her daughters? What issues must be taken into account when someone is considering genetic testing for breast cancer?
3.
A 46-year-old woman reports to you that she wants to undergo mastectomy and oophorectomy because she has a positive family history of breast cancer and is terrified of developing breast or ovarian cancer. Describe the benefits and risks of these surgeries for prophylactic management in women at risk for breast cancer. What postoperative care and teaching are indicated if she has both mastectomy and oophorectomy performed to reduce her risks for breast and ovarian cancer?
4.
Two weeks after having a mastectomy to treat breast cancer, a 37-year-old patient calls you. She is distraught because her husband, who moved out of their bedroom
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immediately after her discharge so that he did not disturb her, has refused to sleep in the same bed or same room with her. How would you address this issue? What resources would you use to address the problem, and what resources would you provide to the patient and her spouse?
5.
A 59-year-old woman with a history of cardiac disease is scheduled for a modified radical mastectomy and breast reconstruction surgery. Describe the preoperative and postoperative care of this patient, including discharge planning.
REFERENCES AND SELECTED READINGS Books American Cancer Society. (2002a). Cancer facts and figures. Atlanta: American Cancer Society. American Cancer Society. (2002b). Cancer statistics 2002. Atlanta: American Cancer Society. Bickley, L. S., & Szilagyi, P. G. (2003). Bates’ guide to physical examination and history taking (8th ed.). Philadelphia: Lippincott Williams & Wilkins. Bland, K. I., & Copeland, E. M. III (Eds.). (1998). The breast: Comprehensive management of benign and malignant diseases. Philadelphia: W. B. Saunders. Dow, K. H. (1999). Pocket guide to breast cancer. Boston: Jones & Bartlett. Dow, K. H. (Ed.) (1996). Contemporary issues in breast cancer. Boston: Jones & Bartlett. Greene, F. L., Page, D. L., Fleming, I. D., et al. (2002). AJCC cancer staging manual (6th ed.). New York: Springer-Verlag. Harris, J. R., Lippman, M. E., Morrow, M., & Hellman, S. (Eds.) (1996). Diseases of the breast. Philadelphia: Lippincott-Raven. Holland, J. C. (Ed.) (1998). Psycho-oncology. New York: Oxford University Press. Love, S. M. (2000). Dr. Susan Love’s breast book. Reading, MA: AddisonWesley. Moore, G. (Ed.). (2000). Women and cancer: A gynecologic oncology nursing perspective (2d ed.). Boston: Jones & Bartlett. National Institutes of Health. (2000). NIH consensus statement: Adjuvant therapy for early-stage breast cancer, 17(4), 1–35. National Institutes of Health. (1997). NIH consensus statement: Breast cancer screening for women ages 40-49. 15(1), 1–35 National Institutes of Health. (1990). NIH consensus statement: Treatment of early-stage breast cancer, 8(6), 1–19. Runowicz, C. D., Petrek, J. A., & Gansler, T. S. (1999). Women and cancer. Atlanta: American Cancer Society. Weber, J., & Kelley, J. (2003). Health assessment in nursing (2d ed.). Philadelphia: Lippincott Williams & Wilkins. Yarbro, C. H., Frogge, M. H., Goodman, M., & Groenwald, S. (Eds.) (2000). Cancer nursing: Principles and practices (5th ed.). Sudbury, MA: Jones & Bartlett.
Journals Asterisks indicate nursing research articles. Breast Cancer Risk and Prevention Chlebowksi, R. T. (2000). Reducing the risk of breast cancer. Primary Care, 343(3), 191–198. Cummings, S. R., Eckert, S., Krueger, K. A., et al. (1999). The effect of raloxifene on risk of breast cancer in postmenopausal women: Results from the MORE randomized trial. Journal of American Medical Association, 281(23), 2189–2197. Dooley, W. C., Ljung, B. M., Veronisi, U., et al. (2001). Ductal lavage for detection of cellular atypia in women at high risk for breast cancer. Journal of the National Cancer Institute, 93(21), 1624–1632. Fisher, B., Constantino, J. P., Wickerham, D. L., et al. (1998). Tamoxifen for prevention of breast cancer. Report of the National Surgical
Adjuvant Breast and Bowel Project P-1 Study. Journal of National Cancer Institute, 90(18), 1371–1388. Frykberg, E. R. (1999). Lobular carcinoma in situ of the breast. Breast Journal, 5(5), 296–303. Gail, M. H., Costantino, J. P., Bryant, J., et al. (1999). Weighing the risks and benefits of tamoxifen treatment for preventing breast cancer. Journal of National Cancer Institute, 91(21), 1829–1846. Gross, R. E., (2000). Breast cancer: Risk factors, screening, and prevention. Seminars in Oncology Nursing, 16(3), 176–184. Hartmann, L. C., Sellers, T. A., Schaid, D. J., et al. (1999). Clinical options for women at high risk for breast cancer. Surgical Clinics of North America, 79(5), 1189–1206. Hartmann, L. C., Schaid, D. J., Woods, J. E., et al. (1999). Efficacy of bilateral prophylactic mastectomy in women with a family history of breast cancer. New England Journal of Medicine, 340(2), 77–84. Hulka, B. S., & Moorman, P. G. (2001). Breast cancer: hormones and other risk factors. Maturitas, 38(1), 103–113. MacDonald, D. J. (2002). Women’s decisions regarding management of breast cancer risk. MedSurg Nursing, 11(4), 183–186. *Machia, J. (2001). Breast cancer: Risk, prevention, and tamoxifen. American Journal of Nursing, 101(4), 26–35. Meijers-Heijboer, H., van Geel, B., van Putten, W. L. J., et al. (2001). Breast cancer after prophylactic bilateral mastectomy in women with a BRCA1 or BRCA2 mutation. New England Journal of Medicine, 345(3), 159–164. Newman, L. A., Keurer, H. M., Hung, K. K., et al. (2000). Prophylactic mastectomy. Journal of the American College of Surgeons, 191(3), 322–330. Vogel, V. (2000). Breast cancer prevention: A review of the current evidence. CA: A Cancer Journal for Clinicians, 50(2), 156–170. Cancer Brown, J., Byers, T., & Thompson, K. (2001). Nutrition during and after cancer treatment: A guide for informed choices by cancer survivors. CA: A Cancer Journal for Clinicians, 51(3), 153–187. English, J. C., Middleton, C., Patterson, J. W., et al. (2000). Cancer of the male breast. International Journal of Dermatology, 39(12), 881–886. Fisher, B., Dignam, J., Wolmark, N., et al. (1999). Tamoxifen in the treatment of intraductal breast cancer: National Surgical Adjuvant Breast and Bowel Project B-24 randomised controlled trial. Lancet, 353(9169), 1993–2000. Mautner, B. D., Schmidt, K. V., & Brennan, M. B. (2000). New diagnostic techniques and treatments for early breast cancer. Seminars in Oncology Nursing, 16(3), 185–196. *Samarel, N., Fawcett J., Tulman, L., et al. (1999). A resource kit for women with breast cancer: Development and evaluation. Oncology Nursing Forum, 26(3), 611–618. Solin, L. J., Kurtz, J., Fourquet, A., et al. (1996). Fifteen-year results of breast conserving and definitive breast irradiation for the treatment of ductal carcinoma in situ of the breast. Journal of Clinical Oncology, 14, 754–763. Smith, T. J., Davidson, N. E., Schapira, D. V. et al. (1999). American Society of Clinical Oncology 1998 update of recommended breast cancer surveillance guidelines. Journal of Clinical Oncology, 17(3), 1080–1082. Weber, E. S. (1997). Questions and answers about breast cancer diagnosis. American Journal of Nursing, 97(10), 34–38. Winchester, D. P., & Cox, J. D. (1998). Standards for diagnosis and management of invasive breast carcinoma. CA: A Cancer Journal for Clinicians, 48(2), 83–107. Winchester, D. P., Jeske, J. M., & Goldschmidt, R. A. (2000). The diagnosis and management of ductal carcinoma in situ of the breast. CA: The Cancer Journal for Clinicians, 50(2), 184–200. Chemotherapy Antman, K. H. (2001). Randomized trials of high dose chemotherapy for breast cancer. Biochimica et Biophyic Acta (BBA/Reviews in Cancer), 1471(3), 89–98. Barse, P. M. (2000). Issues in the treatment of metastatic breast cancer. Seminars in Oncology Nursing, 16(3), 197–205.
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*Berger, A. M., & Higginbotham, P. (2000). Correlates of fatigue during and following adjuvant breast cancer chemotherapy: A pilot study. Oncology Nursing Forum, 27(9), 1443–1448. Capriotti, T. (2001). Monoclonal antibodies: Drugs that combine pharmacology and biotechnology. MedSurg Nursing, 10(2), 89–95. Cloutier, A. O. (2000). Advanced breast cancer: Recent developments in hormonal therapy. Seminars in Oncology Nursing, 16(3), 206–213. Frankel, C. (2000). Nursing management considerations with trastuzumab (Herceptin). Seminars in Oncology Nursing, 16(4), 23–28. Hagmann, M. (2000). Scientific misconduct: Cancer researcher sacked for alleged fraud. Science, 287(5460), 1901–1902. Levine, M. (2001). Clinical practice guidelines for the care and treatment of breast cancer: Adjuvant systemic therapy for node-negative breast cancer (summary of the 2001 update). Canadian Medical Association Journal, 164(2), 213. Levine, M. (2001). Clinical practice guidelines for the care and treatment of breast cancer: Adjuvant systemic therapy for node-positive breast cancer (summary of the 2001 update). Canadian Medical Association Journal, 164(5), 644–646. McGinn, K., & Moore, J. (2001). Metastatic breast cancer: Understanding current management options. Oncology Nursing Forum, 28(3), 507–512. *McPhail, G., & Smith, L. N. (2000). Acute menopause symptoms during adjuvant systemic treatment for breast cancer: A case-control study. Cancer Nursing, 23(6), 430–443. Norton, L. (2001). Theoretical concepts and the emerging role of taxanes in adjuvant therapy. Oncologist, 6, Suppl 3, 30–35. Pasacretta, J. V., & McCorkle, R. (1998). Providing accurate information to women about tamoxifen therapy for breast cancer: Current indications, effects, and controversies. Oncology Nursing Forum, 25(9), 1577–1583. Tyler, T. (1998). The medical management of breast cancer. Lippincott’s Primary Care Practice, 2(2), 176–183. Genetics Boyd, J. (1996). BRCA2 as a low penetrance cancer gene. Journal of the National Cancer Institute, 88(19), 1408–1409. Houshmand, S. L., Campbell, C. T., Briggs, S. E., et al. (2000). Prophylactic mastectomy and genetic testing: an update. Oncology Nursing Forum, 27(10), 1537–1547. Nogueira, S. M., & Appling, S. E. (2000). Breast cancer: Genetics, risks, and strategies. Nursing Clinics of North America, 35(3), 663–669. Press, N., Fishman, J. R., Koenig, B. A. (2000). Collective fear, individualized risk: The social and cultural context of genetic testing for breast cancer. Nursing Ethics, 7(3), 237–249. Schrag, D., Kuntz, K. M., Garber, E., & Weeks, J. C. (1997). Decision analysis: Effects of prophylactic mastectomy and oophorectomy on life expectancy among women with BRCA1 and BRCA2 mutations. New England Journal of Medicine, 335(20), 1401–1408. Zimmerman, V. L. (2002). BRCA gene mutations and cancer. Preventive strategies benefit patients at risk. American Journal of Nursing, 102(8), 28–36. Geriatrics Kimmick, G. G., & Muss, H. B. (2001). Systemic therapy for older women with breast cancer. Oncology, 15(3), 280–291. Nattinger, A. B. (2000). Older women, mammography, and mortality from breast cancer. American Journal of Medicine, 108(2), 174–175. *Utley, R. (1999). The evolving meaning of cancer for long-term survivors of breast cancer. Oncology Nursing Forum, 26(9), 1519–1523. Zoorob, R., Anderson, R., Cefalu, C., et al. (2001). Cancer screening guidelines. American Family Physician, 63(6), 1101–1112. Lymphedema *Coward, D. D. (1999). Lymphedema prevention and management knowledge in women treated for breast cancer. Oncology Nursing Forum, 26(6), 1047–1053. Erickson, V. S., Pearson, M. L., Ganz, P. A., et al. (2001). Arm edema in breast cancer patients. Journal of the National Cancer Institute, 93(2), 96–111. Hull, M. M. (2000). Lymphedema in women treated for breast cancer. Seminars in Oncology Nursing, 16(3), 226–237.
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Petrek, J. A., Pressman, P. I., & Smith, R. A. (2000). Lymphedema: Current issues in research and management. CA: Cancer Journal for Clinicians, 50(5), 292–307. Plastic and Reconstructive Surgery Alderman, A. K., Wilkins, E. G., Lowery, J. C., et al. (2000). Determinants of patient satisfaction in postmastectomy breast reconstruction. Plastic and Reconstructive Surgery, 106 (4), 769–776. Malata, C. M., McIntosh, S. A., & Purushotham, A. D. (2000). Immediate breast reconstruction after mastectomy for cancer. British Journal of Surgery, 87(11), 1455–1472. *Neill, K. M., Armstrong, N., & Burnett, C. B. (1998). Choosing reconstruction after mastectomy: A qualitative analysis. Oncology Nursing Forum, 25(4), 743–750. Reaby, L. L. (1999). Breast restoration decision making. Plastic Surgical Nursing, 19(1), 22–29. Resnick, B., & Belcher, A. E. (2002). Breast reconstruction: Options, answers, and support for patients making a difficult personal decision. American Journal of Nursing, 102(4), 26–33. Rowland, J. H., Desmond, K. A., Meyerowitz, B. E., et al. (2000). Role of breast reconstructive surgery in physical and emotional outcomes among breast cancer survivors. Journal of the National Cancer Institute, 92(17), 1422–1429. Sandau, K. E. (2002). Free TRAM flap breast reconstruction. American Journal of Nursing, 102(4), 36–43. Pregnancy and Breast Cancer Dow, K. H. (2000). Pregnancy and breast cancer. Journal of Obstetrical & Gynecologic Neonatal Nursing, 29(6), 634–640. Gelber, S., Coates, A. S., Goldhirsch, A., et al. (2001). Effects of pregnancy on overall survival after diagnosis of early-stage breast cancer. Journal of Clinical Oncology, 19(6), 1671–1675. Gemignani, M. L., & Petrek, J. A. (1999). Pregnancy after breast cancer. Cancer Control, 6(3), 272–276. Moore, H. C., & Foster, R. S. (2000). Breast cancer and pregnancy. Seminars in Oncology, 27(6), 646–653. Psychological Aspects of Breast Cancer Gray, R. E., Goel, V., Fitch, M. I., et al. (2000). Utilization of professional care services by women with breast cancer. Breast Cancer Research & Treatment, 64(3), 253–258. *Hilton, B. A., Crawford, J. A., & Tarko, M. A. (2000). Men’s perspectives on individual and family coping with their wives’ breast cancer and chemotherapy. Western Journal of Nursing Research, 22(4), 438–459. *Holmberg, S. K., Scott, L. L., Alexy, W., et al. (2001). Relationship issues of women with breast cancer. Cancer Nursing, 24(1), 53–60. *Horden, A. (2000). Intimacy and sexuality for the woman with breast cancer. Cancer Nursing, 23(3), 230–236. Hoskins, C. N., & Haber, J. (2000). Adjusting to breast cancer. American Journal of Nursing, 100(4), 26–32. Utley, R. (1999). The evolving meaning of cancer for long-term survivors of breast cancer. Oncology Nursing Forum, 26(9), 1519–1523. *Walker, B. L., Nail, L. M., & Croyle, R. T. (1999). Does emotional expression make a difference in reactions to breast cancer? Oncology Nursing Forum, 26(6), 1025–1032. Woodward, V., & Webb, C. (2001). Women’s anxieties surrounding breast disorders: A systematic review of the literature. Journal of Advanced Nursing, 33(1), 29–41. *Wonghongkul, T., Moore, S. M., Musil, C., et al. (2000). The influence of uncertainty in illness, stress appraisal, and hope on coping in survivors of breast cancer. Cancer Nursing, 23(6), 422–429. Radiation *Dow, K. H., & Lafferty, P. (2000). Quality of life, survivorship, and psychosocial adjustment of young women with breast cancer after breast-conserving surgery and radiation therapy. Oncology Nursing Forum, 27(10), 1555–1564. *Kolcaba, K., & Fox, C. (1999). The effects of guided imagery on comfort of women with early-stage breast cancer undergoing radiation therapy. Oncology Nursing Forum, 26(1), 67–72. Morrow, M., White, J., Moughan, J., et al. (2001). Factors predicting the use of breast-conserving therapy in stage I and stage II breast carcinoma. Journal of Clinical Oncology, 19(8), 2254–2262.
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Screening, BSE, and Mammography Anderson, M. R., Urban, N., & Etzioni, R. (1999). Community attitudes and mammography use: Does it really matter what other people think? Women Health, 29(3), 83–95. Center for Disease Control Database. (2000). National Center for Health Statistics (via the Internet: http://www.cdc.gov/hchs). Clarke, V. A., & Savage, S. A. (1999). Breast self-examination training: A brief review. Cancer Nursing, 22(4), 320–326. Cole, C. F. (1998). Issues in breast imaging. Lippincott’s Primary Care Practice, 2(2), 141–148. *Faccione, N. C. (1999). Breast cancer screening in relation to access to health services. Oncology Nursing Forum, 26(4), 689–696. Gail, M. H., & Rimer, B. K. (1998). Risk-based recommendations for mammographic screening for women in their forties. Journal of Clinical Oncology, 16(9), 3105–3114. Kolb, T. M., Lichy, J., & Newhouse, J. H. (1998). Occult cancer in women with dense breasts: Detection with screening US: diagnostic yield and tumor characteristics. Radiology, 207(1), 191–199. *Lauver, D. R., Kane J., Bodden, J., et al. (1999). Engagement in breast cancer screening behaviors. Oncology Nursing Forum, 26(3), 545–554. National Institutes of Health. (1997). Consensus statement: Breast cancer screening for women ages 40–49. Norris, T. G. (2001). Benign breast disease. Radiology Technology, 72(3), 245–267. Schnall, M. D. (2001). Application of magnetic resonance imaging to early detection of breast cancer. Breast Cancer Research & Treatment, 3(1), 17–21. Tabar, L., Vitak, B., Tony, H. H., et al. (2001). Beyond randomized controlled trials: Organized mammographic screening substantially reduces breast carcinoma mortality. Cancer, 91(9), 1724–1731. *Yarbrough, S. S., & Braden, C. J. (2001). Utility of health belief model as guide for explaining or predicting breast cancer screening behaviors. Journal of Advanced Nursing, 33(5), 677–688. Surgical Treatment of Breast Cancer Baron, R. H. (1999). Sentinel lymph node biopsy in breast cancer and the role of the oncology nurse. Clinical Journal of Oncology Nursing, 3(1), 17–22. Baron, R. H., Fey, J. V., Raboy, S., et al. (2002). Eighteen sensations after breast cancer surgery: A comparison of sentinel lymph node biopsy and axillary lymph node dissection. Oncology Nursing Forum, 29(4), 651–659. *Burke, C. C., Zabka, C. L., McCarver, K. J., & Singletary, S. E. (1997). Patient satisfaction with 23-hour “short-stay” observation following breast cancer surgery. Oncology Nursing Forum, 24, 645–651. Dell, D. D. (1997). Common questions about ductal carcinoma in situ. American Journal of Nursing, 97(5), 61–65. Gross, R. E. (1998). Current issues in the surgical treatment of early stage breast cancer. Clinical Journal of Oncology Nursing, 2(2), 55–63. Hsueh, E. C., Hansen, N., & Giuliano, A. E. (2000). Intraoperative lymphatic mapping and sentinel lymph node dissection in breast cancer. CA: Cancer Journal for Clinicians, 50(5), 279–291. Kauff, N., Satagopan, J. M., Robson, M. E., et al. (2002). Risk-reducing salpingo-oophorectomy in women with a BRCA1 or BRCA2 mutation. New England Journal of Medicine, 346(21), 1609–1615. *Poole, K., & Lyne, P. A. (2000). The ‘cues’ to diagnosis: Describing the monitoring of activities of women undergoing diagnostic investigations for breast disease. Journal of Advanced Nursing, 31(4), 752–758. Rebbeck, T. R., Lynch, H. T., Neuhausen, S. L., et al. (2002). Prophylactic oophorectomy in carriers of BRCA1 and BRCA2 mutations. New England Journal of Medicine, 346(21), 1616–1622. Solin, L. J., Fourquet, A., Vicini, F. A., et al. (2001). Mammographically detected ductal carcinoma in situ of the breast treated with
breast-conserving surgery and definitive breast irradiation: Longterm outcome and prognostic significance of patient age and margin status. International Journal of Radiation Oncology and Biologic Physics, 50(4), 991–1002. Strozzo, M. D. (1998). An overview of surgical management of stage I and stage II breast cancer for the primary care provider. Lippincott’s Primary Care Practice, 2(2), 160–169. Veronesi, U., Galimberti, V., Zurrida, S., et al. (2001). Sentinel lymph node biopsy as an indicator for axillary dissection in early breast cancer. European Journal of Cancer, 37(4), 454–458.
RESOURCES AND WEBSITES Agencies American Cancer Society, 1599 Clifton Road, NE, Atlanta, GA 303294251; (404) 320-3333; http://www.cancer.org (extensive professional and patient literature is available, including booklets on reconstruction, radiation, and chemotherapy). American Cancer Society Breast Health Department, 19 West 56th Street, New York, NY 10019; (212) 586-8700; http://www. cancer.org. American Society of Plastic and Reconstructive Surgeons, 444 East Algonquin Avenue, Arlington Heights, IL 60006; (800) 635-0635; http://www.plastic surgery.org. National Alliance of Breast Cancer Organizations, 1180 Avenue of the Americas, 2nd Floor, New York, NY 10036; (212) 719-0154; e-mail:
[email protected]. National Breast Cancer Coalition, 1707 L Street NW, Suite 1060, Washington, DC 20036; (202) 296-7477; http://www.natlbcc.org. (This activist group has raised funds and consciousness levels regarding breast cancer and was instrumental in obtaining funds for research on prevention.) National Cancer Institute, Public Inquiry Section, Office of Cancer Communications, National Cancer Institute, Building 31, Room 10 A 24, Bethesda, MD 20892; (800) 422-6237; http://www.cancernet. nci.nih.gov. (Patient materials can be ordered on the following topics: biopsies, treatment options, mastectomy, radiation, chemotherapy, reconstruction, diet, and clinical trials.) National Lymphedema Network, 2211 Post Street, Suite 404, San Francisco, CA 94115; (800) 541-3259; E-mail:
[email protected]. Oncology Nursing Society, 501 Holiday Drive, Pittsburgh, PA 152202749; (412) 921-7373; http://www.ons.org. Reach to Recovery Program—I Can Cope Program. (Information available through local American Cancer Society chapters). Susan G. Komen Breast Cancer Foundation, 5005 LBJ Freeway, Suite 370, Dallas, TX 75244; (800) I’M AWARE (1-800-462-9273); http://www.komen.org. Y-ME Breast Cancer Support Program, 212 West Van Buren Street, Chicago, IL 60607; (800) 221-2141; http://www.y-me.org.
Websites cancernet.nci.gov (produced jointly by the International Cancer Information Center, NCI, and the Office of Cancer Communications). mskcc.org (information on Memorial Sloan-Kettering Cancer Center’s programs and services for the prevention, cure, and control of cancer). nysernet.org/bcic (serves as a clearinghouse for information on breast cancer). oncolink.upenn.edu (University of Pennsylvania’s educational resource for patients with cancer). access.digex.net/∼mkragen/index.html (a guide to cancer resources). cancercareinc.org (produced by Cancer Care, Inc., an organization supported through educational grants and private contributions that provides telephone services and sponsors free teleconference seminars in addition to its Web-based services).
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Assessment and Management of Problems Related to Male Reproductive Processes LEARNING OBJECTIVES
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On completion of this chapter, the learner will be able to: 1. Describe structures and function of the male reproductive system. 2. Discuss nursing assessment of the male reproductive system and 3. 4. 5. 6. 7.
identify diagnostic tests that complement assessment. Discuss the causes and management of male sexual dysfunction. Compare the types of prostatectomy with regard to advantages and disadvantages. Use the nursing process as a framework for care of the patient undergoing prostatectomy. Describe the nursing management of patients with testicular cancer. Describe the various conditions affecting the penis, including pathophysiology, clinical manifestations, and management.
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isorders of the male reproductive system include a wide variety of conditions that usually affect both the urinary and reproductive systems. Because these disorders focus on the genitalia and in some instances sexuality, the patient may experience anxiety and embarrassment. Nurses must recognize the patient’s need for privacy as well as his need for education. This requires an openness to discuss critical and sensitive issues with the patient as well as effective assessment, management, and communication on the part of the nurse.
Anatomic and Physiologic Overview In the male, several organs serve as parts of both the urinary tract and the reproductive system. Disorders in the male reproductive organs may interfere with the functions of one or both of these systems. As a result, diseases of the male reproductive system are usually treated by a urologist. The structures in the male reproductive system are the testes, the vas deferens (ductus deferens) and the seminal vesicles, the penis, and certain accessory glands, such as the prostate gland and Cowper’s gland (bulbourethral gland) (Fig. 49-1).
TESTICULAR DEVELOPMENT The testes are formed in the embryo within the abdominal cavity near the kidney. During the last month of fetal life, they descend posterior to the peritoneum and pierce the abdominal wall in the groin. Later, they progress along the inguinal canal into the scrotum. In this descent, they are accompanied by blood vessels, lymphatics, nerves, and ducts, which support the tissue and make up the spermatic cord. This cord extends from the internal inguinal ring through the abdominal wall and the inguinal canal to the scrotum. As the testes descend into the scrotum, a tubular extension of peritoneum accompanies them. Normally, this tissue is obliterated during fetal development, the only remaining portion being that which covers the testes, the tunica vaginalis. (When this peritoneal process is not obliterated but remains open into the abdominal cavity, a potential sac remains into which abdominal contents may enter to form an indirect inguinal hernia.) The testes are encased in the scrotum, which keeps them at a slightly lower temperature than the rest of the body to facilitate spermatogenesis (production of sperm). The testes consist of numerous seminiferous tubules in which the spermatozoa form. Collecting tubules transmit the spermatozoa into the epididymis,
Glossary benign prostatic hyperplasia (BPH): noncancerous enlargement or hypertrophy of the prostate. BPH is the most common pathologic condition in older men and the second most common cause of surgical intervention in men older than age 60 years. Bowen’s disease: form of squamous cell carcinoma in situ of the penile shaft circumcision: excision of the foreskin, or prepuce, of the glans penis cryosurgery of the prostate: localized treatment of the prostate by application of freezing temperatures cryptorchidism: most common congenital defect, characterized by failure of one or both of the testes to descend into the scrotum epididymitis: infection of the epididymis that usually descends from an infected prostate or urinary tract; also may develop as a complication of gonorrhea erectile dysfunction: also called impotence; the inability to either achieve or maintain an erection sufficient to accomplish sexual intercourse hydrocele: a collection of fluid, generally in the tunica vaginalis of the testis, although it also may collect within the spermatic cord nocturia: urination during the night orchiectomy: surgical removal of one or both of the testes orchitis: inflammation of the testes (testicular congestion) caused by pyogenic, viral, spirochetal, parasitic, traumatic, chemical, or unknown factors penile cancer: represents about 0.5% of malignancies in men in the United States; can involve the glans, the body of the
penis, the urethra, and regional or distant lymph nodes penis: male organ for copulation and urination; consists of glans penis, body, and root Peyronie’s disease: buildup of fibrous plaques in the sheath of the corpus cavernosum, causing curvature of the penis when it is erect phimosis: condition in which the foreskin is constricted so that it cannot be retracted over the glans; can occur congenitally or from inflammation and edema priapism: an uncontrolled, persistent erection of the penis occurring from either neural or vascular causes, including medications, sickle cell thrombosis, leukemic cell infiltration, spinal cord tumors, and tumor invasion of the penis or its vessels prostate cancer: the most common cancer in men; risk factors include increasing age, African American race, and possibly a higher-fat diet; the genetic association of prostate cancer and the increased incidence within certain families is being investigated prostate gland: gland that lies just below the neck of the bladder, surrounds the urethra, and is traversed by the ejaculatory duct, a continuation of the vas deferens; produces a secretion that is chemically and physiologically suitable to the needs of the spermatozoa in their passage from the testes prostate-specific antigen (PSA): substance that is produced by the prostate gland and measured in a blood specimen; PSA levels are increased with prostate cancer; the PSA test is used in combination with digital rectal examination to detect prostate cancer
prostatism: obstructive and irritative symptom complex that includes increased frequency and hesitancy in starting urination, a decrease in the volume and force of the urinary stream, acute urinary retention, and recurrent urinary tract infections prostatitis: inflammation of the prostate gland caused by infectious agents (bacteria, fungi, mycoplasma) or various other problems (eg, urethral stricture, prostatic hyperplasia) spermatogenesis: production of sperm in the testes testes: the ovoid sex glands encased in the scrotum; the testes produce sperm testicular cancer: the most common cancer in men 15 to 35 years of age and the second most common malignancy in those 35 to 39 years of age; its cause is unknown testosterone: male sex hormone secreted by the testes; induces and preserves the male sex characteristics transurethral resection of the prostate (TUR or TURP): resection of the prostate through endoscopy; the surgical and optical instrument is introduced directly through the urethra to the prostate, and the gland is then removed in small chips with an electrical cutting loop varicocele: an abnormal dilation of the veins of the pampiniform venous plexus in the scrotum (the network of veins from the testis and the epididymis, which constitute part of the spermatic cord) vasectomy: also called male sterilization; ligation and transection of part of the vas deferens, with or without removal of a segment of the vas to prevent the passage of the sperm from the testes
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Assessment and Management of Problems Related to Male Reproductive Processes
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Urinary bladder Ampulla Seminal vesicle Symphysis pubis Ejaculatory duct Vas deferens Prostate gland Corpus cavernosum
Bladder
Urethra Penis Glans penis
Seminal vesicles Prepuce
Prostate gland
Urethral meatus
Vas deferens
Testis
Urethra
Scrotum
Anus Bulbourethral gland Perineum Vas deferens Epididymis
FIGURE 49-1
Structures of the male reproductive system. Adapted from Willis, M. C. (1996). Medical terminology: The language of health care. Baltimore: Williams & Wilkins.
a hoodlike structure lying on the testes and containing winding ducts that lead into the vas deferens. This firm, tubular structure passes upward through the inguinal canal to enter the abdominal cavity behind the peritoneum. It then extends downward toward the base of the bladder. An outpouching from this structure is the seminal vesicle, which acts as a reservoir for testicular secretions. The tract is continued as the ejaculatory duct, which passes through the prostate gland to enter the urethra. Testicular secretions take this pathway when they exit the penis during ejaculation.
penile skin—the foreskin—which may be retracted to expose the glans. However, many men have had the foreskin removed (circumcision) as newborns. The body of the penis is composed of erectile tissues containing numerous blood vessels that become distended, leading to an erection during sexual excitement. The urethra, which passes through the penis, extends from the bladder through the prostate to the distal end of the penis.
Assessment
GLANDULAR FUNCTION
HEALTH HISTORY AND CLINICAL MANIFESTATIONS
The testes have a dual function: the formation of spermatozoa from the germinal cells of the seminiferous tubules and the secretion of the male sex hormone testosterone, which induces and preserves the male sex characteristics. The prostate gland lies just below the neck of the bladder. It surrounds the urethra and is traversed by the ejaculatory duct, a continuation of the vas deferens. This gland produces a secretion that is chemically and physiologically suitable to the needs of the spermatozoa in their passage from the testes. Cowper’s gland lies below the prostate within the posterior aspect of the urethra. This gland empties its secretions into the urethra during ejaculation, providing lubrication. The penis has a dual function: it is the organ for copulation and for urination. Anatomically, it consists of the glans penis, body, and root. The glans penis is the soft, rounded portion at the distal end of the penis. The urethra, the tube that carries urine, opens at the tip of the glans. The glans is naturally covered or protected by elongated
Assessment of male reproductive function begins with an evaluation of urinary function and symptoms. This assessment also includes a focus on sexual function as well as manifestations of sexual dysfunction. The patient is asked about his usual state of health and any recent change in general physical and sexual activity. Any symptoms or changes in function are explored fully and described in detail. These symptoms may include those associated with an obstruction caused by an enlarged prostate gland: increased urinary frequency, decreased force of urine stream, “double” or “triple” voiding (the patient needs to urinate two or three times over a period of several minutes to completely empty his bladder). The patient is also assessed for dysuria, hematuria, and hematospermia (blood in the ejaculate). Assessment of sexual function and dysfunction is an essential part of every health history. The extent of the history will depend on the patient’s presenting symptoms and the presence of factors that may affect sexual function: chronic illnesses (eg, diabetes,
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multiple sclerosis, stroke, cardiac disease), use of medications that affect sexual function (eg, many antihypertensive and anticholesterolemic medications, psychotropic agents), stress, and alcohol use. Discussing sexuality with patients with an illness or disability can be uncomfortable for nurses and other health care providers. Health care professionals may unconsciously have stereotypes related to sexuality about people who are ill or disabled (eg, ill or disabled persons are asexual or should remain sexually inactive). In addition, patients are often embarrassed to initiate a discussion about these issues with their health care providers (Hughes, 2000). Because changes in sexual functioning are a common concern of patients, it is important to address these issues when obtaining the health history. By initiating an assessment about sexual concerns, the nurse demonstrates that changes in sexual functioning are valid topics for discussion and provides a safe environment for discussing these sensitive topics. The PLISSIT (permission, limited information, specific suggestions, intensive therapy) model of sexual assessment and intervention may be used to provide a framework for nursing interventions (Annon, 1976). This model begins by asking the patient’s permission to discuss sexual functioning. Limited information about sexual function may then be provided to the patient. As the discussion progresses, the nurse may offer specific suggestions for interventions. For some individuals, a professional who specializes in sex therapy may provide more intensive therapy as needed.
PHYSICAL ASSESSMENT In addition to the customary aspects of the physical examination, two essential components address disorders of the male genital or reproductive system: the digital rectal examination and the testicular examination.
Digital Rectal Examination The digital rectal examination (DRE) is recommended as part of the regular health checkup for every man older than 40 years of age; it is invaluable in screening for cancer of the prostate gland. The DRE enables the examiner to assess the size, shape, and consistency of the prostate gland (Fig. 49-2). Tenderness of the prostate gland on palpation and the presence and consis-
B
A
tency of any nodules are noted. Although having this examination may be embarrassing for the patient, it is an important screening tool.
Testicular Examination The male genitalia are inspected for abnormalities and palpated for masses. The scrotum is palpated carefully for nodules, masses, or inflammation. Examining the scrotum can reveal such disorders as hydrocele, hernia, or tumor of the testis. The penis is inspected and palpated for ulcerations, nodules, inflammation, and discharge. The testicular examination provides an excellent opportunity to instruct the patient about techniques for testicular self-examination and its importance in early detection of testicular cancer (discussed later in this chapter). This selfexamination should begin during adolescence. Gerontologic Considerations As men age, the prostate gland enlarges, prostate secretion decreases, the scrotum hangs lower, the testes become smaller and more firm, and pubic hair becomes sparser and stiffer. Changes in gonadal function include a decline in plasma testosterone levels and reduced production of progesterone (Table 49-1). Other changes include decreasing sexual function, slower sexual responses, an increased incidence of genitourinary tract cancer, and urinary incontinence for various reasons. Male reproductive capability is maintained with advancing age. Although degenerative changes occur in the seminiferous tubules, spermatogenesis (production of sperm) continues. Sexual function, however, involving libido (desire) and potency, decreases. Vascular problems cause about half of the cases of impotence in men older than 50 years of age. Hypogonadism occurs in up to one fourth of older men. The relationship of hypogonadism to impotence is uncertain. This decline is more evident in men older than 70 years but is also noted in men in their 60s. In older men, the sexual response slows. Erection takes longer in men older than 50 years of age, and full erections may not be attained until orgasm. Sexual function is affected by several factors, such as psychological problems, illnesses, and medications. In general, the sexual act takes longer. In older men, ejaculatory control increases; however, if the erection is partially
FIGURE 49-2 (A) Palpation of the prostate gland during digital rectal examination (DRE) enables the examiner to assess the size, shape, and texture of the gland. (B) The prostate is round, with a palpable median sulcus or groove separating the two lobes. It should feel rubbery and free of nodules and masses.
Chapter 49
Table 49-1
Assessment and Management of Problems Related to Male Reproductive Processes
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• Age-Related Changes in Male Reproductive System
AGE-RELATED CHANGES
PHYSIOLOGIC CHANGES
MANIFESTATIONS
Decrease in sex hormone secretion, especially testosterone
Decreased muscle strength and sexual energy
Changes in sexual response: prolonged time to reach full erection, rapid penile detumescence and prolonged refractory period Decrease in number of viable sperm Smaller testes
Shrinkage and loss of firmness of testes; thickening of seminiferous tubules Fibrotic changes of corpora cavernosa Enlargement of prostate gland
Erectile dysfunction Weakening of prostatic contractions Hyperplasia of prostate gland Signs and symptoms of obstruction of lower urinary tract (urgency, frequency, nocturia)
lost, there may be difficulty in attaining a full erection again, and resolution may occur without orgasm. Sexual activity is closely correlated with the man’s sexual activity of his earlier years; if he was more active than average as a young man, he will most likely continue to be more active than average in his later years. Cancers of the kidney, bladder, prostate, and penis all have increased incidence in men older than 50 years of age. DRE and screening tests for hematuria may uncover a higher percentage of malignancies at earlier stages. Urinary incontinence in the elderly man may have many causes, including medications and age-related conditions, such as neurologic diseases or benign prostatic hyperplasia (BPH; also referred to as hypertrophy and called an enlarged prostate by the lay public). Diagnostic tests are performed to exclude reversible causes of urinary incontinence. For some patients with severe incontinence, augmentation cystoplasty (repair of the bladder) with placement of an artificial urinary sphincter may help alleviate this problem.
ULTRASONOGRAPHY
Diagnostic Evaluation
TESTS OF MALE SEXUAL FUNCTION
Diagnostic studies that relate to the male reproductive organs and the ability to participate in sexual activity include the following.
PROSTATE-SPECIFIC ANTIGEN TEST The prostate gland produces a substance known as prostatespecific antigen (PSA). It can be measured in a blood specimen, and levels increase with prostate cancer. Many factors can increase PSA levels, including BPH, prostate cancer, and infections of the prostate and urinary tract. PSA levels are measured in nanograms per milliliter (ng/mL). The PSA test and DRE are used to detect prostate cancer (Smith, Cokkinides, von Eschenbach, et al., 2002). The range of values considered normal is 0.2 to 4.0 ng/mL. Values over 4.0 are considered elevated. An elevated PSA level is not a specific indicator of prostate cancer. A number of conditions (eg, BPH, transurethral resection of the prostate, acute urinary retention, and acute prostatitis) can also cause an elevated PSA level in the absence of prostate cancer. Despite these limitations, in combination with other procedures, PSA is useful in identifying men at risk and in monitoring patients following treatment for cancer of the prostate (Barry, 2001). A PSA test, along with DRE, is recommended by the American Cancer Society annually for men at high risk, specifically those with a family history of prostate cancer and for African American men.
Transrectal ultrasound (TRUS) studies may be performed in patients with abnormalities detected by DRE or those with elevated PSA levels. After DRE, a lubricated, condom-covered, rectal probe transducer is inserted into the rectum along the anterior wall. Water may be introduced to the condom to help transmit sound waves to the prostate. TRUS may be used in detecting nonpalpable prostate cancers and in staging localized prostate cancer. Needle biopsies of the prostate are commonly guided by TRUS.
PROSTATE FLUID OR TISSUE ANALYSIS Specimens of prostate fluid or tissue may be obtained for culture when disease or inflammation of the prostate gland is suspected. A biopsy of the prostate gland may be necessary to obtain tissue for histologic examination. This may be performed at the time of prostatectomy or by means of a perineal or transrectal needle biopsy.
If the patient cannot engage in sexual intercourse to his satisfaction, a detailed history is obtained. Nocturnal penile tumescence tests may be conducted in a sleep laboratory to monitor changes in penile circumference during sleep (using a mercury strain gauge placed around the penis); the results help to identify the cause of erectile dysfunction. Arterial blood flow to the penis is measured with the Doppler probe. Nerve conduction tests and psychological evaluations are also part of the diagnostic workup and are usually conducted by a specialized team of health care providers.
Disorders of Male Sexual Function ERECTILE DYSFUNCTION Erectile dysfunction, also called impotence, is the inability to achieve or maintain an erection sufficient to accomplish intercourse. The man may report decreased frequency of erections, inability to achieve a firm erection, or rapid detumescence (subsiding of erection). Incidence ranges from 25% to 50% in men older than 65 years of age. The physiology of erection and ejaculation is complex and involves sympathetic and parasympathetic components. At the time of erection, pelvic nerves carry parasympathetic impulses that dilate the smaller blood vessels of the region and increase blood flow to the penis, expanding the corpora cavernosa.
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Erectile dysfunction has both psychogenic and organic causes. Psychogenic causes include anxiety, fatigue, depression, and pressure to perform sexually. Organic impotence, however, may account for more impotence than previously realized. Organic causes include occlusive vascular disease, endocrine disease (diabetes, pituitary tumors, hypogonadism with testosterone deficiency, hyperthyroidism, and hypothyroidism), cirrhosis, chronic renal failure, genitouri-nary conditions (radical pelvic surgery), hematologic conditions (Hodgkin’s disease, leukemia), neurologic disorders (neuropathies, parkinsonism, spinal cord injury, multiple sclerosis), trauma to the pelvic or genital area, alcohol, medications (Chart 49-1), and drug abuse.
Assessment and Diagnostic Findings The diagnosis of erectile dysfunction requires a sexual and medical history; an analysis of presenting symptoms; a physical examination, including a neurologic examination; a detailed assessment of all medications, alcohol, and drugs used; and various laboratory studies. Nocturnal penile tumescence tests are conducted in sleep laboratories to monitor changes in penile circumference. In healthy men, nocturnal penile erections closely parallel rapid eye movement (REM) sleep in occurrence and duration. Organically impotent men show inadequate sleeprelated erections that correspond to their waking performance. The nocturnal penile tumescence test can help to determine whether erectile impotence has an organic or psychological cause. Arterial blood flow to the penis is measured using a Doppler probe. In addition, nerve conduction tests and extensive psychological evaluations are carried out. Figure 49-3 describes the evaluation and treatment of men with erectile dysfunction.
Chart 49-1
• PHARMACOLOGY
Classes of Medications Associated With Erectile Dysfunction Antiadrenergics and antihypertensives: guanethidine (Ismelin), clonidine (Catapres), hydralazine (Apresoline), metoprolol (Lopressor) Anticholinergics and phenothiazines: prochlorperazine (Compazine), trihexyphenidyl (Artane) Anti-seizure agents: carbamazepine (Tegretol) Antifungals: ketoconazole (Nizoral) Antihormone (prostate cancer treatment): flutamide (Eulexin), leuprolide (Lupron) Antipsychotics: haloperidol (Haldol), chlorpromazine (Thorazine) Antispasmodics: oxybutynin (Ditropan) Anxiolytics, sedative–hypnotics, tranquilizers: lorazepam (Ativan), triazolam (Halcion) Beta-blockers: nadolol (Corgard) Calcium channel blockers: nifedipine (Adalat, Procardia) Carbonic anhydrase inhibitors: acetazolamide (Diamox) H2 antagonists: nizatidine (Axid) Nonsteroidal anti-inflammatory drugs: naproxen (Naprosyn) Thiazide diuretics: hydrochlorothiazide (HydroDIURIL) Tricyclic antidepressants: amitriptyline (Elavil), desipramine (Norpramin)
FIGURE 49-3 Evaluation and treatment of men with erectile dysfunction. From Lue, T. F. (2000). Erectile dysfunction. New England Journal of Medicine, 342(24), 1807. © 2000 Massachusetts Medical Society. All rights reserved. Used with permission.
Chapter 49
Assessment and Management of Problems Related to Male Reproductive Processes
Medical Management Treatment, which depends on the cause, can be medical, surgical, or both (Table 49-2). Nonsurgical therapy includes treating associated conditions, such as alcoholism, and readjusting hypertensive agents or other medications. Endocrine therapy may be instituted for erectile dysfunction secondary to hypothalamicpituitary-gonadal dysfunction and may reverse the condition. Insufficient penile blood flow may be treated with vascular surgery. Patients with erectile dysfunction from psychogenic causes are referred to a health care provider or therapist specializing in sexual dysfunction. Patients with erectile dysfunction secondary to organic causes may be candidates for penile implants. PHARMACOLOGIC THERAPY Sildenafil (Viagra) is an oral medication for erectile dysfunction (Eid, 2000). When it is taken about 1 hour before sex, an erection can occur with stimulation; the erection can last about 60 to 120 minutes. Despite the effectiveness of this medication, it does have side effects: headache, flushing, and dyspepsia. Sildenafil is contraindicated in patients who take organic nitrates and should be used with caution in patients with retinopathy, especially those with diabetic retinopathy (Chart 49-2). Other pharmacologic measures to induce erections include injecting vasoactive agents, such as alprostadil, papaverine, and phentolamine, directly into the penis. Complications include priapism (a persistent abnormal erection) and development of fibrotic plaques at the injection sites. Alprostadil is also formulated in a gel pellet that can be inserted into the urethra to create an erection. PENILE IMPLANTS Penile implants are available in two types: the semirigid rod and the inflatable prosthesis. The semirigid rod (eg, the Small-Carrion prosthesis) leaves the man with a permanent semierection. The inflatable prosthesis simulates natural erections and natural flaccidity. Complications after implantation include infection, erosion of the prosthesis through the skin (more common with the semirigid rod than with the inflatable prosthesis), and persistent pain, which may require removal of the implant. Cystoscopic surgery, such as transurethral resection of the prostate (TUR or TURP), is more difficult with a semirigid rod than with the inflatable prosthesis. Factors to consider in choosing a prosthesis are the patient’s activities of daily living and social activities and the expectations of the patient and his partner. Ongoing counseling for the patient and his partner is usually necessary to help them in adapting to the prosthesis. NEGATIVE-PRESSURE DEVICES Negative-pressure (vacuum) devices may also be used to induce an erection. A plastic cylinder is placed over the flaccid penis, and negative pressure is applied. When an erection is attained, a constriction band is placed around the base of the penis to maintain the erection. Although many men find this method satisfactory, others experience premature loss of penile rigidity or pain when applying suction or during intercourse.
Nursing Management Personal satisfaction and the ability to sexually satisfy a partner are common concerns of patients. Men with illnesses and disabilities may need the assistance of a sex therapist to find, implement, and integrate their sexual beliefs and behaviors into a healthy and sat-
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isfying lifestyle. The nurse can inform patients that support groups for men with erectile dysfunction and their partners have been established. Information about Impotence Anonymous for patients and I-Anon for their partners can be found at the end of this chapter.
EJACULATION PROBLEMS Premature ejaculation occurs when a man cannot control the ejaculatory reflex and, once aroused, reaches orgasm before or shortly after intromission. It is the most common dysfunction in men. Inhibited or retarded ejaculation is the involuntary inhibition of the ejaculatory reflex. The spectrum of responses includes occasional ejaculation through intercourse or self-stimulation or the complete inability to ejaculate under any circumstances. Treatment modalities depend on the nature and severity of the ejaculation problem. Behavioral therapies may be indicated for people with premature ejaculation; these therapies often involve the man and his sexual partner. “Homework” assignments are often given to the couple to encourage them to identify their sexual needs and to communicate those needs to each other. In some cases, pharmacologic and behavioral therapy together may be effective. Neurologic disorders (eg, spinal cord injury, multiple sclerosis, neuropathy secondary to diabetes), surgery (prostatectomy), and medications are the most common causes of inhibited ejaculation. Chemical, vibratory, and electrical stimulation have been used with some success. Treatment is usually multidisciplinary and addresses the physical and psychological factors that are often involved in inhibited ejaculation (Lue, 2000). For men with retrograde ejaculation, the urine may be collected after ejaculation; sperm is then collected from the urine for use in artificial insemination. In men with spinal cord injury, electroejaculation may be used to obtain sperm for artificial insemination. The effects of trauma, chronic illness, and physical disability on sexual function can be profound. In addition to psychogenic factors, the physical changes associated with illness and injury can impair sexual function.
Infections of the Male Genitourinary Tract Acute uncomplicated cystitis in adult men is uncommon but occasionally occurs in men whose sexual partners have vaginal infections with Escherichia coli. Asymptomatic bacteriuria may also occur from genitourinary manipulation, catheterization, or instrumentation. Urinary tract infections in the male are discussed in Chapter 45. The incidence of sexually transmitted diseases (STDs) is increasing in men and women. STDs are most common in young, sexually active people, with the incidence higher in men than women (U.S. Surgeon General, 2001). STDs affect people from all walks of life—from all social, educational, economic, and racial backgrounds. Several diseases are classified as STDs: urethritis (gonococcal and nongonococcal), genital ulcers (genital herpes infections, primary syphilis, chancroid, granuloma inguinale, and lymphogranuloma venereum), genital warts (human papillomavirus [HPV]), scabies, pediculosis pubis, molluscum contagiosum, hepatitis and enteric infections, proctitis, and acquired immunodeficiency syndrome (AIDS). Trichomoniasis and STDs characterized by genital ulcers are thought to increase susceptibility to human immunodeficiency virus (HIV) infection. Trichomoniasis is associated with nonchlamydial, nongonococcal urethritis.
Table 49-2
• Treatments for Erectile Dysfunction ADVANTAGES AND DISADVANTAGES
METHOD
DESCRIPTION
DURATION
Penile implants • Semirigid rod • Inflatable
Surgically implanted into corpus cavernosum
Reliable Requires surgery Healing takes up to 3 weeks Subsequent cystoscopic surgery is difficult Semirigid rod results in permanent semierection
Indefinite Inflatable prosthesis: saline returns from penile receptacle to reservoir
Induction of erection with vacuum; maintained with constriction band around base of penis
Few side effects Cumbersome to use before intercourse Vasocongestion of penis can cause pain or numbness
To prevent penile injury, constriction band must not be left in place for longer than 1 hour
Smooth muscle relaxant causing blood to flow into penis
Can cause headache and diarrhea Contraindicated for men taking organic nitrates Used with caution in patients with retinopathy, especially diabetic retinopathy
Taken orally 1 hour before intercourse Stimulation is required to achieve erection Erection can last 1 hour
Smooth muscle relaxant causing blood to flow into penis
Firm erections are achievable in more than 50% of cases Pain at injection site; plaque formation, risk of priapism
Injection 20 minutes before intercourse Erection can last up to 1 hour
Penile implant
Negative-pressure (vacuum) devices
Penile vacuum pump
Pharmacologic therapy • Oral medication (sildenafil [Viagra])
VIAGRA
Oral medication
• Injection (alprostadil, papaverine, phentolamine)
Penile injection
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(continued)
Chapter 49
Table 49-2
Assessment and Management of Problems Related to Male Reproductive Processes
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• Treatments for Erectile Dysfunction (Continued)
METHOD
DESCRIPTION
• Urethral suppository (alprostadil)
Smooth muscle relaxant causing blood to flow into penis
ADVANTAGES AND DISADVANTAGES
DURATION
May be used twice a day Not recommended with pregnant partners
Inserted 10 minutes before intercourse Erection can last up to 1 hour
Penile suppository
Treatment of STDs must be targeted at the patient as well as his or her sexual partners and sometimes the unborn child. A thorough history that includes a sexual history is crucial to identify patients at risk and to direct care and teaching. Partners of men with STDs must also be examined, treated, and counseled to prevent reinfection and complications in both partners and to
limit the spread of the disease. Sexual abstinence during treatment and recovery is advised to prevent the transmission of STDs (CDC, 2002). Using latex condoms for at least 6 months after completion of treatment is recommended to decrease transmission of HPV infections as well as other STDs. Because patients with one STD may also have another STD, it is important to
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examine and test for other STDs. Use of spermicides with nonoxynol 9 (“N-9”) is discouraged as they do not protect against HIV infection and may increase the risk for transmission of the virus (van Damme, 2000; CDC, 2002). See Chapters 52 and 70 for more detailed discussions of HIV infection and AIDS and other STDs.
Conditions of the Prostate PROSTATITIS Prostatitis is an inflammation of the prostate gland caused by infectious agents (bacteria, fungi, mycoplasma) or other conditions (eg, urethral stricture, prostatic hyperplasia). E. coli is the most commonly isolated organism. Microorganisms are usually carried to the prostate from the urethra. Prostatitis may be classified as bacterial or abacterial, depending on the presence or absence of microorganisms in the prostatic fluid.
Clinical Manifestations Symptoms of prostatitis may include perineal discomfort, burning, urgency, frequency, and pain with or after ejaculation. Prostatodynia (pain in the prostate) is manifested by pain on voiding or perineal pain without evidence of inflammation or bacterial growth in the prostate fluid. Acute bacterial prostatitis may produce sudden fever and chills and perineal, rectal, or low back pain. Urinary symptoms, such as dysuria, frequency, urgency, and nocturia (urination during the night), may occur. Some patients do not have symptoms. Chronic bacterial prostatitis is a major cause of relapsing urinary tract infection in men. Symptoms are usually mild, consisting of frequency, dysuria, and occasionally urethral discharge. High temperature and chills are uncommon. Complications of prostatitis may include swelling of the prostate gland and urinary retention. Other complications include epididymitis, bacteremia, and pyelonephritis.
Assessment and Diagnostic Findings The diagnosis of prostatitis requires a careful history, culture of prostate fluid or tissue, and occasionally a histologic examination of the tissue. To locate the source of a lower genitourinary infection (bladder neck, urethra, prostate), it is necessary to collect a divided urinary specimen for segmental urine culture. After cleaning the glans penis and retracting the foreskin (if present), the patient voids 10 to 15 mL of urine into a container. This represents urethral urine. Without interrupting the urinary stream, he collects 50 to 75 mL of urine in a second container; this represents bladder urine. If the patient does not have acute prostatitis, the physician immediately performs a prostatic massage and collects any prostatic fluid that is expressed into a third container. If it is not possible to collect prostatic fluid, the patient voids a small quantity of urine. The specimen may contain the bacteria present in the prostatic fluid. Urinalysis after prostate examination commonly reveals many white blood cells.
Medical Management The goal of therapy for acute bacterial prostatitis is to avoid the complications of abscess formation and septicemia. A broadspectrum antibiotic agent (to which the causative organism is sen-
sitive) is administered for 10 to 14 days. Intravenous administration of the agent may be necessary to achieve high serum and tissue levels; the agent may be administered at home. The patient is encouraged to remain on bed rest to alleviate symptoms quickly. Comfort is promoted with analgesic agents (to relieve pain), antispasmodic medications and bladder sedatives (to relieve bladder irritability), sitz baths (to relieve pain and spasm), and stool softeners (to prevent pain from straining). Chronic bacterial prostatitis is difficult to treat because most antibiotics diffuse poorly from the plasma into the prostatic fluid. Nevertheless, antibiotics may be prescribed, including trimethoprim-sulfamethoxazole (TMP-SMZ) or a fluoroquinolone. Continuous therapy with low-dose antibiotics to suppress the infection may also be indicated. The patient is advised that the urinary tract infection may recur and is taught to recognize its symptoms. In addition, treatment for chronic prostatitis may include reducing the retention of prostatic fluid by ejaculation through sexual intercourse or masturbation. Other treatments include antispasmodics, sitz baths, stool softeners, and evaluation of sexual partners to reduce the possibility of crossinfection. The treatment of nonbacterial prostatitis is directed toward relieving symptoms.
Nursing Management If the patient experiences symptoms of acute prostatitis (fever, severe pain and discomfort, inability to urinate, malaise), he may be hospitalized for intravenous antibiotic therapy. Nursing management includes administration of prescribed antibiotics and provision of comfort measures, including prescribed analgesic agents and sitz baths. The patient with chronic prostatitis is usually treated on an outpatient basis and needs to be instructed about the importance of continuing antibiotic therapy. PROMOTING HOME AND COMMUNITY-BASED CARE Teaching Patients Self-Care. The nurse instructs the patient to complete the prescribed course of antibiotics. If intravenous antibiotics are to be administered at home, the nurse instructs the patient and family about correct and safe administration. Arrangements for home care to oversee administration may be needed. Hot sitz baths (10 to 20 minutes) may be taken several times daily. Fluids are encouraged to satisfy thirst but are not “forced” because an effective medication level must be maintained in the urine. Foods and liquids that have diuretic action or that increase prostatic secretions, such as alcohol, coffee, tea, chocolate, cola, and spices, should be avoided. During periods of acute inflammation, sexual arousal and intercourse should be avoided. To minimize discomfort, the patient should avoid sitting for long periods. Medical follow-up is necessary for at least 6 months to 1 year because prostatitis caused by the same or different organisms can recur.
BENIGN PROSTATIC HYPERPLASIA (ENLARGED PROSTATE) In many patients older than 50 years, the prostate gland enlarges, extending upward into the bladder and obstructing the outflow of urine by encroaching on the vesical orifice. This condition is known as benign prostatic hyperplasia (BPH), the enlargement, or hypertrophy, of the prostate. BPH is one of the most common pathologic conditions in older men (McConnell, 1998).
Chapter 49
Assessment and Management of Problems Related to Male Reproductive Processes
Clinical Manifestations Examination reveals a prostate gland that is large, rubbery, and nontender. The cause is uncertain, but evidence suggests that hormones initiate hyperplasia of the supporting stromal tissue and the glandular elements in the prostate (McConnell, 1998). The hypertrophied lobes may obstruct the vesical neck or prostatic urethra, causing incomplete emptying of the bladder and urinary retention. As a result, a gradual dilation of the ureters (hydroureter) and kidneys (hydronephrosis) can occur. Urinary tract infections may result from urinary stasis, because some urine remains in the urinary tract and serves as a medium for infective organisms.
Assessment and Diagnostic Findings The obstructive and irritative symptom complex (referred to as prostatism) includes increased frequency of urination, nocturia, urgency, hesitancy in starting urination, abdominal straining with urination, a decrease in the volume and force of the urinary stream, interruption of the urinary stream, dribbling (urine dribbles out after urination), a sensation that the bladder has not been completely emptied, acute urinary retention (when more than 60 mL of urine remains in the bladder after urination), and recurrent urinary tract infections. Ultimately, azotemia (accumulation of nitrogenous waste products) and renal failure can occur with chronic urinary retention and large residual volumes. Generalized symptoms may also be noted, including fatigue, anorexia, nausea, vomiting, and epigastric discomfort. Other disorders producing similar symptoms include urethral stricture, prostate cancer, neurogenic bladder, and urinary bladder stones. A physical examination with DRE and diagnostic studies may be performed to determine the degree to which the prostate is enlarged, the presence of any changes in the bladder wall, and the efficiency of renal function. These tests may include urinalysis and urodynamic studies to assess urine flow. Renal function tests, including serum creatinine levels, may be performed to determine if there is renal impairment from prostatic back-pressure and to evaluate renal reserve. Complete blood studies are performed. Because hemorrhage is a major complication of prostate surgery, all clotting defects must be corrected. A high percentage of patients with BPH have cardiac or respiratory complications, or both, because of their age; therefore, cardiac and respiratory function is also assessed.
Medical Management The treatment plan depends on the cause of BPH, the severity of the obstruction, and the patient’s condition. If the patient is admitted on an emergency basis because he cannot void, he is immediately catheterized. The ordinary catheter may be too soft and pliable to advance through the urethra into the bladder. In such cases, a thin wire called a stylet is introduced (by a urologist) into the catheter to prevent the catheter from collapsing when it encounters resistance. In severe cases, metal catheters with a pronounced prostatic curve may be used. Sometimes an incision is made into the bladder (a suprapubic cystostomy) to provide drainage. Although prostatectomy (described later in the chapter) to remove the hyperplastic prostatic tissue is frequently performed, other treatment options are available. These include “watchful waiting,” transurethral incision of the prostate (TUIP), balloon dilation, alpha-blockers, 5-alpha-reductase inhibitors, transurethral
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laser resection, transurethral needle ablation, and microwave thermotherapy (Lepor, 1998; Mebust, 1998; McCullough, 1998). Watchful waiting is the appropriate treatment for many patients because the likelihood of progression of the disease or the development of complications is unknown. Patients are monitored periodically for severity of symptoms, physical findings, laboratory tests, and diagnostic urologic tests. Alpha-adrenergic receptor blockers (eg, terazosin [Hytrin]) relax the smooth muscle of the bladder neck and prostate. These agents help to reduce obstructive symptoms in many patients. Because the hormonal component of BPH has been identified, one method of treatment involves hormonal manipulation with antiandrogen agents, such as finasteride (Proscar). In clinical studies, 5-alpha-reductase inhibitors such as finasteride have been effective in preventing the conversion of testosterone to dihydrotestosterone (DHT). With decreased levels of DHT, suppression of glandular cell activity and decreases in prostate size have been demonstrated. Side effects of these medications include gynecomastia (breast enlargement), erectile dysfunction, and flushing. With ultrasound guidance, resection of the prostate can be accomplished with lasers. The treated tissue either vaporizes or becomes necrotic and sloughs. This treatment is delivered in the outpatient setting and generally results in less postoperative bleeding than a traditional surgical prostatectomy. Transurethral needle ablation uses low-level radiofrequencies to produce localized heat to destroy prostate tissue while sparing the urethra, nerves, muscles, and membranes. The radiofrequencies are delivered by thin needles placed into the prostate gland from a catheter. The body then resorbs the dead tissue. In microwave thermotherapy, heat is applied to the hypertrophied prostatic tissue. A transurethral probe is inserted into the urethra, and microwaves are carefully directed to the prostate tissue. A water-cooling system helps to minimize damage to the urethra and decreases the discomfort from the procedure. The tissue becomes necrotic and sloughs. Saw palmetto is a botanical remedy used for symptoms of mild to moderate BPH such as urinary frequency and decreased force of urine stream (Gerber, 2000; Marks, Partin, Epstein et al., 2000; Wilt, Ishani, Stark et al., 1998). It is theorized that saw palmetto works by interfering with the conversion of testosterone to DHT. In addition, saw palmetto may directly block the ability of DHT to stimulate prostate cell growth. It should not be used with finasteride or medications containing estrogen.
CANCER OF THE PROSTATE Prostate cancer is the most common cancer in men other than nonmelanoma skin cancer and the second most common cause of cancer deaths in American men older than 55 years of age (Greenlee et al., 2001). About one in five men in the United States develop prostate cancer. It is estimated that 189,000 new cases of prostate cancer and 30,200 deaths occur annually (American Cancer Society, 2002). Prostate cancer rates are twice as high in African American men than in Caucasian men, and African American men are more likely to die of prostate cancer than men in any other racial or ethnic group. To address this issue, Agho and Lewis (2001) assessed knowledge of prostate cancer and the use of prostate cancer screening services among 108 African American men. The men were unable to answer most of the 21 questions on the test with more than 70% accuracy, although individuals younger than 40 years of age were
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more knowledgeable than older men. Despite their increased risk for prostate cancer, only 47% of the men in the sample who were 40 years or older had prostate cancer screening as part of their annual physical examination. Knowledge about prostate cancer was found to be negatively correlated with education, age, and income. A culturally sensitive promotional campaign has been identified as an important strategy to increase awareness of the racial disparities in the incidence of prostate cancer and mortality rates. Nurses are in an ideal position to use these research findings to improve the health of African American men by teaching and counseling them about prostate cancer, screening, and treatment. Risk factors for prostate cancer include increasing age: the incidence of prostate cancer increases rapidly after the age of 50 years, and more than 70% of cases occur in men over 65 years of age. African American men have the highest incidence of prostate cancer in the world. Prostate cancer is common in the United States and northwestern Europe but is rare in Asia, Africa, Central America, and South America. A familial predisposition may occur in 5% to 10% of cases of prostate cancer. Having a father or brother with prostate cancer doubles the risk; the risk increases further if several relatives have had prostate cancer and if the relatives were young at diagnosis. A diet high in red meat and fat increases the risk for prostate cancer (American Cancer Society, 2002). Large-scale studies are in progress to determine if prostate cancer can be prevented by use of selected supplements or finasteride (Proscar).
Clinical Manifestations Cancer of the prostate in its early stages rarely produces symptoms. The symptoms that develop from urinary obstruction occur late in the disease. This cancer tends to vary in its course. If the neoplasm is large enough to encroach on the bladder neck, signs and symptoms of urinary obstruction occur: difficulty and frequency of urination, urinary retention, and decreased size and force of the urinary stream. Other symptoms may include blood in the urine or semen and painful ejaculation. Hematuria may result if the cancer invades the urethra or bladder, or both. Prostate cancer can metastasize to bone and lymph nodes. Symptoms related to metastases include backache, hip pain, perineal and rectal discomfort, anemia, weight loss, weakness, nausea, and oliguria (decreased urine output). Unfortunately, these symptoms may be the first indications of prostate cancer.
Assessment and Diagnostic Findings When prostate cancer is detected early, the likelihood of cure is high. Every man older than 40 years of age should have a DRE as part of his regular health checkup. Routine repeated rectal palpation of the gland (preferably by the same examiner) is important because early cancer may be detected as a nodule within the substance of the gland or as an extensive hardening in the posterior lobe. The more advanced lesion is “stony hard” and fixed. DRE also provides useful clinical information about the rectum, anal sphincter, and quality of stool.
NURSING RESEARCH PROFILE 49-1
Impact of Prostate Cancer Fitch, M. I., Gray, R., Franssen, E., & Johnson, B. (2000). Men’s perspectives on the impact of prostate cancer: Implications for oncology nurses. Oncology Nursing Forum, 27(8), 1255–1263.
Purpose This study was conducted to describe the experience of and support used by men with prostate cancer and to compare those with recurrent prostate cancer and those without recurrent disease. Study Sample and Design This was a descriptive study of men with prostate cancer: 120 men with recurrent prostate cancer and 845 men without recurrent prostate cancer living in Canada. Consecutive subjects were recruited through urology offices and self-help groups. A 52-item survey developed by the researchers was used to obtain information from the subjects. Descriptive data analysis addressed demographic characteristics, problems experienced, assistance received for problems, factors surrounding emotional support (eg, satisfaction with communication, satisfaction with information received, benefits of self-help groups), and impact of illness and treatment on lifestyle (including relationships with partners, children, and friends; employment opportunities and work life; financial status; leisure time activities; mental health; and household responsibilities). The two groups were compared on relevant variables. Findings Men in both groups reported physical and psychological problems, although the incidence of these problems was higher in men with recurrent disease. Sexual dysfunction was the most frequently identified problem in both groups, but among those with recurrent disease, a significantly higher percentage reported problems with side effects, pain, and anger. Although few men reported having difficulty talking with their health care providers, 10% of men with recurrent disease
had trouble doing so compared to 2% of those without recurrent disease (p < 0.025). The percentage of men with recurrent disease who reported dissatisfaction with the information that was provided was higher in the areas of possible side effects or symptoms (31% vs. 14%, p < 0.005) and medical condition (25% vs. 10%, p < 0.005) than that of men without recurrent disease. Men in both groups indicated that they received inadequate help with problems such as side effects, incontinence, sexual dysfunction, and pain. Overall, family and friends were the most frequent sources of support when men needed to talk, followed by medical professionals and self-help groups. The subjects also identified the need for more information about possible emotional reactions to the disease, how to arrange to speak to another man with prostate cancer, alternative therapies, diet and nutrition. Nursing Implications Nurses should conduct early and ongoing comprehensive patient assessments, including physical as well as psychosocial components, to determine patient needs so that they can provide timely and effective interventions. Patients at high risk of experiencing psychosocial difficulties include those who do not have the social networks available to discuss their experiences. To enhance coping with the consequences of prostate cancer and its treatment, particularly in those with recurrent disease, nurses need to teach patients about the disease and provide an opportunity for them to discuss their concerns. In addition, assessment findings will help guide the creation and provision of effective interventions. Referral to self-help groups may be indicated, particularly in the absence of social support from family and friends.
Chapter 49
Assessment and Management of Problems Related to Male Reproductive Processes
The diagnosis of prostate cancer is confirmed by a histologic examination of tissue removed surgically by transurethral resection, open prostatectomy, or transrectal needle biopsy. Fineneedle aspiration is a quick, painless method of obtaining prostate cells for cytologic examination. The procedure is helpful for determining the stage of disease as well. Most prostate cancers are diagnosed when a man seeks medical attention for symptoms of urinary obstruction or after abnormalities are found by DRE. Incidentally detected cancer with transurethral resection of the prostate for clinically benign disease and prostatism occurs in 10% to 20% of patients. Rarely do patients have other signs and symptoms, such as azotemia (nitrogen compounds in the blood), weakness, anemia, or bone pain. PSA, a neutral serine protease, is produced by the normal and neoplastic ductal epithelium of the prostate and secreted into the glandular lumen (Brawer, Cheli, Neaman et al., 2000; Kalish & McKinlay, 1999). A simple blood test can be used to measure PSA levels. The concentration of PSA in the blood is proportional to the total prostatic mass. Although the PSA level indicates the presence of prostate tissue, it does not necessarily indicate malignancy. PSA testing is routinely used to monitor the patient’s response to cancer therapy and to detect local progression and early recurrence of prostate cancer. The combination of DRE and PSA testing appears to be a cost-effective method for detecting prostate cancer. The American Cancer Society recommends that, beginning at age 50, an annual DRE and PSA measurement be offered to men who have a life expectancy of at least 10 years and to younger men (age 45 years or older) who are at high risk. Risk factors include strong familial predisposition (two or more affected primary relatives) and African American race (Smith et al., 2000). Transrectal ultrasound (TRUS) studies are indicated for men who have elevated PSA levels and abnormal DRE findings. TRUS studies help in detecting nonpalpable prostate cancers and assist with staging localized prostate cancer. Needle biopsies of the prostate are commonly guided by TRUS. Other tests include bone scans to detect metastatic bone disease, skeletal x-rays to identify bone metastases, excretory urography to detect changes caused by ureteral obstruction, renal function tests, and computed tomography (CT) scans or lymphangiography to identify metastases in the pelvic lymph nodes. The radiolabeled monoclonal antibody Capromab Pendetide with Indium-111 (ProstaScint) is an antibody that is attracted to the prostate-specific membrane antigen found on prostate cancer cells (Narayan et al., 2000). The radioactive element attached to the antibody is then visible with scanning, allowing detection of disease spread. This study is used to detect spread of prostate cancer in the lymph nodes or other parts of the body in newly diagnosed men who have apparently localized prostate cancer and who are thought to be at high risk for metastasis. In addition, men who have undergone a prostatectomy and who develop a rising PSA level may also be evaluated with this study.
Sexual Complications Men with prostate cancer commonly experience sexual dysfunction before the diagnosis is made. Each treatment (see discussion that follows) for prostate cancer further increases the incidence of sexual problems. With nerve-sparing radical prostatectomy, the chance of recovering erections is better for men who are younger and in whom both neurovascular bundles are spared. Hormonal therapy also affects the central nervous system mechanisms that mediate sexual desire and arousability. Sildenafil (Viagra) has been found to be effective for treating erectile dysfunction in younger men after radical retropubic pros-
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tatectomy, especially if the neurovascular bundles were preserved (Zagaja, Mhoon, Aikens et al., 2000). In addition, sildenafil can improve erectile function in men with partial or moderate erectile dysfunction following radiation therapy for localized prostate cancer (Zelefsky, 1999).
Medical Management Treatment is based on the stage of the disease and the patient’s age and symptoms. Partin and associates (1997) combined PSA level with the clinical stage and pathologic grade of the tumor to create a nomogram to predict the pathologic stage of localized prostate cancer. This nomogram can be useful in making treatment decisions and predicting treatment outcomes. Nursing care of the patient with cancer of the prostate is summarized in the Plan of Nursing Care. SURGICAL MANAGEMENT A radical prostatectomy (removal of the prostate and seminal vesicles) remains the standard surgical procedure for patients who have early-stage, potentially curable disease and a life expectancy of 10 years or more (Carroll et al., 2001). Sexual impotence follows radical prostatectomy, and 5% to 10% of patients have various degrees of urinary incontinence (Bishoff, Motley, Optenberg et al., 1998). RADIATION THERAPY If prostate cancer is detected in its early stage, the treatment may be curative radiation therapy: either teletherapy with a linear accelerator or interstitial irradiation (implantation of radioactive seeds of iodine or palladium), also referred to as brachytherapy (Carroll et al., 2001). Teletherapy involves about 6 to 7 weeks of daily (5 days/week) radiation treatments. Interstitial seed implantation is performed under anesthesia. About 80 to 100 seeds are placed with ultrasound guidance, and the patient returns home after the procedure. Exposure of others to radiation is minimal, but close contact with pregnant women and infants should be avoided for up to 2 months. Radiation safety guidelines include straining urine for seeds and using a condom during sexual intercourse for 2 weeks after implantation to catch seeds that may pass through the urethra. Side effects, which usually are transitory, include inflammation of the rectum, bowel, and bladder (proctitis, enteritis, and cystitis) due to their proximity to the prostate and the radiation doses (Horwitz & Hanks, 2000; Krumholtz et al., 2000; Ragde, Grado, Nadir et al., 2000). Irritation of the bladder and urethra from radiation therapy can cause pain with urination and during ejaculation until the irritation subsides. There is a greater preservation of sexual potency, however, with radiation therapy than with surgery. For locally advanced prostate cancer, hormonal treatments before and during radiation therapy are frequently used to improve local control and disease-free survival (Lue, 2000). HORMONAL THERAPY Hormonal therapy is one method used to control rather than cure prostate cancer (Carroll et al., 2001). In the early 1940s, it was determined that most prostate cancers were androgendependent and could be controlled by androgen withdrawal. Hormonal therapy for advanced prostate cancer suppresses androgenic stimuli to the prostate by decreasing the circulating plasma testosterone levels or interrupting the conversion to or (text continues on page 1501)
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Plan of Nursing Care The Patient With Prostate Cancer Nursing Interventions
Rationale
Expected Outcomes
Nursing Diagnosis: Anxiety related to concern and lack of knowledge about the diagnosis, treatment plan, and prognosis Goal: Reduced stress and improved ability to cope 1. Obtain health history to determine the following: a. Patient’s concerns b. His level of understanding of his health problem c. His past experience with cancer d. Whether he knows his diagnosis of malignancy and its prognosis e. His support systems and coping methods 2. Provide education about diagnosis and treatment plan: a. Explain in simple terms what diagnostic tests to expect, how long they will take, and what will be experienced during each test. b. Review treatment plan and allow patient to ask questions. 3. Assess his psychological reaction to his diagnosis/prognosis and how he has coped with past stresses. 4. Provide information about institutional and community resources for coping with prostate cancer: social services, support groups, community agencies
1. Nurse clarifies information and facilitates patient’s understanding and coping.
• Appears relaxed • States that anxiety has been reduced or relieved
• Demonstrates understanding of illness and treatment when questioned
• Engages in open communication with others
2. Helping the patient to understand the diagnostic tests and treatment plan will help decrease his anxiety and promote cooperation.
3. This information provides clues in determining appropriate measures to facilitate coping. 4. Institutional and community resources can help the patient and family cope with the illness and treatment on an ongoing basis.
Nursing Diagnosis: Urinary retention related to urethral obstruction secondary to prostatic enlargement or tumor and loss of bladder tone due to prolonged distention/retention Goal: Improved pattern of urinary elimination 1. Determine patient’s usual pattern of urinary function. 2. Assess for signs and symptoms of urinary retention: amount and frequency of urination, suprapubic distention, complaints of urgency and discomfort. 3. Catheterize patient to determine amount of residual urine. 4. Initiate measures to treat retention: a. Encourage assuming normal position for voiding. b. Recommend using Valsalva maneuver. c. Administer prescribed cholinergic agent. d. Monitor effects of medication. 5. Consult with physician regarding intermittent or indwelling catheterization; assist with procedure as required. 6. Monitor catheter function; maintain sterility of closed system; irrigate as required. 7. Prepare patient for surgery if indicated.
1. Provides a baseline for comparison and goal to work toward 2. Voiding 20 to 30 mL frequently and output less than intake suggests retention.
• Voids at normal intervals • Reports absence of frequency, urgency, or bladder fullness
• Displays no palpable suprapubic distention after voiding
3. Determines amount of urine remaining in bladder after voiding 4. Promotes voiding a. Usual position provides relaxed conditions conducive to voiding. b. Valsalva maneuver exerts pressure to force urine out of bladder. c. Stimulates bladder contraction d. If unsuccessful, another measure may be required. 5. Catheterization will relieve urinary retention until the specific cause is determined; it may be an obstruction that can be corrected only surgically. 6. Adequate functioning of catheter is to be ensured to empty bladder and to prevent infection. 7. Surgical removal of obstruction may be necessary.
• Maintains balanced intake and output
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Plan of Nursing Care The Patient With Prostate Cancer (Continued) Nursing Interventions
Rationale
Expected Outcomes
Nursing Diagnosis: Deficient knowledge related to the diagnosis of: cancer, urinary difficulties, and treatment modalities Goal: Understanding of the diagnosis and ability to care for self 1. Encourage communication with the patient. 2. Review the anatomy of the involved area. 3. Be specific in selecting information that is relevant to the patient’s particular treatment plan. 4. Identify ways to reduce pressure on the operative area after prostatectomy: a. Avoid prolonged sitting (in a chair, long automobile rides), standing, walking. b. Avoid straining, such as during exercises, bowel movement, lifting, and sexual intercourse. 5. Familiarize patient with ways of attaining/maintaining bladder control. a. Encourage urination every 2 to 3 hours; discourage voiding when supine. b. Avoid drinking cola and caffeine beverages; urge a cutoff time in the evening for drinking fluids to minimize frequent voiding during the night. c. Describe perineal exercises to be performed every hour. d. Develop a schedule with patient that will fit into his routine. 6. Demonstrate catheter care; encourage his questions; stress the importance of position of urinary receptacle.
1. This is designed to establish rapport and trust. 2. Orientation to one’s anatomy is basic to understanding its function. 3. This is based on the treatment plan; as it varies with each patient, individualization is desirable. 4. This is to prevent bleeding; such precautions are in order for 6 to 8 weeks postoperatively.
• Discusses his concerns and problems freely • Asks questions and shows interest in his condition
• Describes activities that help or hinder recovery
• Identifies ways of attaining/maintaining bladder control
• Demonstrates satisfactory technique and understanding of catheter care
• Lists signs and symptoms that must be reported should they occur
5. These measures will help control frequency and dribbling and aid in preventing retention. a. By sitting or standing, patient is more likely to empty his bladder. b. Spacing the kind and amount of liquid intake will help to prevent frequency.
c. Exercises will assist him in starting and stopping the urinary stream. d. A schedule will assist in developing a workable pattern of normal activities. 6. By requiring a return demonstration of care, collection, and emptying of the device, he will become more independent and also can prevent backflow of urine, which can lead to infection.
Nursing Diagnosis: Imbalanced nutrition: less than body requirements related to decreased oral intake because of anorexia, nausea, and vomiting caused by cancer or its treatment Goal: Maintain optimal nutritional status 1. Assess the amount of food eaten. 2. Routinely weigh patient. 3. Elicit patient’s explanation of why he is unable to eat more. 4. Cater to his individual food preferences (eg, avoiding foods that are too spicy or too cold). 5. Recognize effect of medication or radiation therapy on appetite.
1. This assessment will help determine nutrient intake. 2. Weighing the patient on the same scale under similar conditions can help monitor changes in weight. 3. His explanation may present easily corrected practices. 4. He will be more likely to consume larger servings if food is palatable and appealing. 5. Many chemotherapeutic agents and radiation therapy promote anorexia.
• Responds positively to his favorite foods • Assumes responsibility for his oral hygiene • Notes increase in weight after improved appetite
(continued)
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Plan of Nursing Care The Patient With Prostate Cancer (Continued) Nursing Interventions
Rationale
6. Inform patient that alterations in taste can occur.
6. Aging and the disease process can reduce taste sensitivity. In addition, smell and taste can be altered as a result of the body’s absorption of byproducts of cellular destruction (brought on by malignancy and its treatment). 7. Prevention of nausea and vomiting can stimulate appetite.
7. Use measures to control nausea and vomiting: a. Administer prescribed antiemetics, around the clock if necessary. b. Provide oral hygiene after vomiting episodes. c. Provide rest periods after meals. 8. Provide frequent small meals and a comfortable and pleasant environment. 9. Assess patient’s ability to obtain and prepare foods.
Expected Outcomes
8. Smaller portions of food are less overwhelming to the patient. 9. Disability or lack of social support can hinder the patient’s ability to obtain and prepare foods.
Nursing Diagnosis: Sexual dysfunction related to effects of therapy: chemotherapy, hormonal therapy, radiation therapy, surgery Goal: Ability to resume/enjoy modified sexual functioning 1. Determine from nursing history what effect patient’s medical condition is having on his sexual functioning. 2. Inform patient of the effects of prostate surgery, orchiectomy (when applicable), chemotherapy, irradiation, and hormonal therapy on sexual function. 3. Include his partner in developing understanding and in discovering alternative, satisfying close relations with each other.
1. Usually decreased libido and, later, impotence may be experienced. 2. Treatment modalities may alter sexual function, but each is evaluated separately with regard to its effect on a particular patient. 3. Often the bonds between a couple are strengthened with new appreciation and support that had not been evident before the current illness.
• Describes the reasons for changes in sexual functioning
• Discusses with appropriate health care •
personnel alternative approaches and methods of sexual expression Includes partner in discussions related to changes in sexual function
Nursing Diagnosis: Pain related to progression of disease and treatment modalities Goal: Relief of pain 1. Evaluate nature of patient’s pain, its location and intensity using pain rating scale. 2. Avoid activities that aggravate or worsen pain. 3. Because pain is usually related to bone metastasis, ensure that patient’s bed has a bed board on a firm mattress. Also, protect the patient from falls/injuries. 4. Provide support for affected extremities. 5. Prepare patient for radiation therapy if prescribed. 6. Administer analgesics or opioids at regularly scheduled intervals as prescribed. 7. Initiate bowel program to prevent constipation.
1. Determining nature and causes of pain and its intensity helps to select proper relief modality and provide baseline for later comparison. 2. Bumping the bed is an example of an action that can intensify the patient’s pain. 3. This will provide added support and is more comfortable. Protecting the patient from injury protects him from additional pain. 4. More support, coupled with reduced movement of the part, helps in pain control. 5. Radiation therapy may be effective in controlling pain. 6. Analgesics alter perception of pain and provide comfort. Regularly scheduled analgesics around the clock rather than PRN provide more consistent pain relief. 7. Opioid analgesics and inactivity contribute to constipation.
• Reports relief of pain • Expects exacerbations, reports their quality and intensity, and obtains relief
• Uses pain relief strategies appropriately and effectively
• Identifies strategies to avoid complications of analgesic use
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Plan of Nursing Care The Patient With Prostate Cancer (Continued) Nursing Interventions
Rationale
Expected Outcomes
Nursing Diagnosis: Impaired physical mobility and activity intolerance related to tissue hypoxia, malnutrition, and exhaustion and to spinal cord or nerve compression from metastases Goal: Improved physical mobility 1. Assess for factors causing limited mobility (eg, pain, hypercalcemia, limited exercise tolerance). 2. Provide pain relief by administering prescribed medications. 3. Encourage use of assistive devices: cane, walker. 4. Involve significant others in helping patient with range-of-motion exercises, positioning, and walking. 5. Provide positive reinforcement for achievement of small gains. 6. Assess nutritional status.
1. This information offers clues to the cause; if possible, cause is treated.
• Achieves improved physical mobility • Relates that short-term goals are encouraging him because they are attainable
2. Analgesics/opioids allow the patient to increase his activity more comfortably. 3. Support may offer the security needed to become mobile. 4. Assistance from partner or others encourages patient to repeat activities and achieve goals. 5. Encouragement stimulates improvement of performance. 6. See Nursing Diagnosis: Imbalanced nutrition: less than body requirements.
Collaborative Problems: Hemorrhage, infection, bladder neck obstruction Goal: Absence of complications 1. Alert the patient to changes that may occur (after discharge) and that need to be reported: a. Continued bloody urine; passing blood clots b. Pain; burning around the catheter c. Frequency of urination
d. Diminished urinary output e. Increasing loss of bladder control
1. Certain changes signal beginning complications, which call for nursing and medical interventions. a. Hematuria with or without blood clot formation may occur postoperatively. b. Indwelling urinary catheters may be a source of infections. c. Urinary frequency may be caused by urinary tract infections or by bladder neck obstruction, resulting in incomplete voiding. d. Bladder neck obstruction decreases the amount of urine that is voided. e. Urinary incontinence may be a result of urinary retention.
binding of dihydrotestosterone. As a result, the prostatic epithelium atrophies (decreases). This effect is accomplished either by orchiectomy (removal of the testes) or by the administration of medications. Orchiectomy lowers plasma testosterone levels because about 93% of circulating testosterone is of testicular origin (7% is from the adrenal glands). As a result, the testicular stimulus required for continued prostatic growth is removed, resulting prostatic atrophy. Although orchiectomy does not cause the side effects associated with other hormonal therapies, it carries a significant emotional impact. Estrogen therapy, usually in the form of diethylstilbestrol (DES), has long been used to inhibit the gonadotropins responsible for testicular androgenic activity, thereby removing the androgenic hormone that promotes the growth of the malignancy. DES relieves symptoms of advanced prostate cancer, reduces tumor size, decreases pain from metastatic nodules, and pro-
• Experiences no bleeding or passage of blood clots
• Reports no pain around the catheter • Experiences normal frequency or urination
• Reports normal urinary output • Maintains bladder control
motes well-being. However, DES significantly increases the risk for thromboembolism, pulmonary embolism, myocardial infarction, and stroke. Other side effects of estrogen therapy include impotence, decreased libido, difficulty in achieving orgasm, decreased sperm production, and gynecomastia (enlargement of breasts in men). Newer hormonal therapies include the luteinizing hormone– releasing hormone (LH-RH) agonists (leuprolide [Lupron] and goserelin [Zoladex]) and antiandrogen agents, such as flutamide (Eulexin). LH-RH suppresses testicular androgen, whereas flutamide causes adrenal androgen suppression (Carroll et al., 2001). Cyproterone acetate is a synthetic progesterone derivative that provides effective, competitive inhibition of androgens at the target cells. In contrast to estrogen, the newer hormonal agents are associated with a lower incidence of cardiovascular side effects, gynecomastia, and decreased sexual function. Hot flushing can occur with orchiectomy or LH-RH agonist therapy because these
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agents increase hypothalamic activity, which stimulates the thermoregulatory centers of the body. OTHER THERAPIES Cryosurgery of the prostate is used to ablate prostate cancer in patients who could not physically tolerate surgery or in those with recurrent prostate cancer. Transperineal probes are inserted into the prostate under ultrasound guidance to freeze the tissue directly. Chemotherapy, such as doxorubicin, cisplatin, and cyclophosphamide, may also be used. Keeping the urethral passage patent may require repeated transurethral resections. When this is impractical, catheter drainage is instituted by way of the suprapubic or transurethral route. For men with advanced prostate cancer, palliative measures are indicated. Although cure is unlikely with advanced prostate cancer, many men survive for long intervals apparently free of metastatic disease. If prostate cancer metastasizes to the bones, these bone lesions can be very painful. Opioid and nonopioid medications are used to control the pain. In addition, externalbeam radiation therapy can be delivered to skeletal lesions to relieve pain. Radiopharmaceuticals, such as strontium-89 and samarium153, can also be intravenously injected to treat multiple sites of bone metastases (Cherney, 2000). Antiandrogen therapies are used in an effort to reduce the circulating androgens. If antiandrogen therapies are not effective, medications such as prednisone and mitoxantrone have been effective in reducing pain and improving quality of life. With advanced prostate cancer, blood transfusions are administered to maintain adequate hemoglobin levels when bone marrow is replaced by tumor.
THE PATIENT UNDERGOING PROSTATE SURGERY Prostate surgery may be indicated for the patient with BPH or prostate cancer. The objectives before prostate surgery are to assess the patient’s general health status and to establish optimal renal function. Prostate surgery should be performed before acute urinary retention develops and damages the upper urinary tract and collecting system or, in the case of prostate cancer, before cancer progresses.
Surgical Procedures Several approaches can be used to remove the hypertrophied portion of the prostate gland: transurethral resection of the prostate (TURP), suprapubic prostatectomy, perineal prostatectomy, retropubic prostatectomy, and transurethral incision of the prostate (TUIP) (Table 49-3). In these approaches, the surgeon removes all hyperplastic tissue, leaving behind only the capsule of the prostate. The transurethral approaches (TURP, TUIP) are closed procedures; the other three are open procedures (ie, a surgical incision is required). The procedure chosen depends on the underlying disorder, the patient’s age and physical status, and patient preference. TRANSURETHRAL RESECTION OF THE PROSTATE TURP, the most common procedure used, can be carried out through endoscopy. The surgical and optical instrument is introduced directly through the urethra to the prostate, which can then be viewed directly. The gland is removed in small chips with an electrical cutting loop (Fig. 49-4A). This procedure, which requires no incision, may be used for glands of varying size and is
ideal for patients who have small glands and those who are considered poor surgical risks. This approach usually requires an overnight hospital stay. Strictures are more frequent, and repeated procedures may be necessary because the residual prostatic tissue can grow back. TURP rarely causes erectile dysfunction, but it may cause retrograde ejaculation because removing the prostatic tissue at the bladder neck can cause the seminal fluid to flow backward into the bladder rather than forward through the urethra during ejaculation. SUPRAPUBIC PROSTATECTOMY Suprapubic prostatectomy is one method of removing the gland through an abdominal incision. An incision is made into the bladder, and the prostate gland is removed from above (see Fig. 49-4B). Such an approach can be used for a gland of any size, and few complications occur, although blood loss may be greater than with the other methods. Another disadvantage is the need for an abdominal incision, with the concomitant hazards of any major abdominal surgical procedure. PERINEAL PROSTATECTOMY Perineal prostatectomy involves removing the gland through an incision in the perineum (see Fig. 49-4C ). This approach is practical when other approaches are not possible and is useful for an open biopsy. Postoperatively, the wound may easily become contaminated because the incision is near the rectum. Incontinence, impotence, and rectal injury are more likely with this approach. RETROPUBIC PROSTATECTOMY Retropubic prostatectomy, another technique, is more common than the suprapubic approach. The surgeon makes a low abdominal incision and approaches the prostate gland between the pubic arch and the bladder without entering the bladder (see Fig. 49-4D). This procedure is suitable for large glands located high in the pelvis. Although blood loss can be better controlled and the surgical site is easier to visualize, infections can readily start in the retropubic space. TRANSURETHRAL INCISION OF THE PROSTATE Transurethral incision of the prostate (TUIP) is another procedure used in treating BPH. An instrument is passed through the urethra (see Fig. 49-4E ). One or two incisions are made in the prostate and prostate capsule to reduce the prostate’s pressure on the urethra and to reduce urethral constriction. TUIP is indicated when the prostate gland is small (30 g or less) and is an effective treatment for many cases of BPH. TUIP can be performed on an outpatient basis and has a lower complication rate than other invasive prostate procedures (Mebust, 1998). LAPAROSCOPIC RADICAL PROSTATECTOMY Laparoscopic radical prostatectomy is a method recently developed in France. Although not yet widespread in the United States, it is anticipated that this procedure will be widely used in place of more extensive surgery for patients with localized prostate cancer. The laparoscopic approach provides better visualization of the surgical site and surrounding areas. Preliminary data suggest that patients who undergo this procedure have less bleeding and reduced need for blood transfusion, a shorter hospital stay, less postoperative pain, and more rapid return to normal activity compared to open radical prostatectomy (Rassweiler, Sentker, Seemann et al., 2001). Further research is needed to assess long-term outcomes.
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Assessment and Management of Problems Related to Male Reproductive Processes
Complications Complications depend on the type of prostatectomy performed and may include hemorrhage, clot formation, catheter obstruction, and sexual dysfunction. All prostatectomies carry a risk of impotence because of potential damage to the pudendal nerves. In most instances, sexual activity may be resumed in 6 to 8 weeks, the time required for the prostatic fossa to heal. During ejaculation, the seminal fluid goes into the bladder and is excreted with the urine. (The anatomic changes in the posterior urethra lead to retrograde ejaculation.) A vasectomy may be performed during surgery to prevent infection from spreading from the prostatic urethra through the vas and into the epididymis. After total prostatectomy (usually for cancer), impotence almost always results. For the patient who does not want to give up sexual activity, options are available to produce erections sufficient for sexual intercourse: prosthetic penile implants, negativepressure (vacuum) devices, and pharmacologic interventions (see earlier discussion in this chapter).
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NURSING PROCESS: THE PATIENT UNDERGOING PROSTATECTOMY Assessment The nurse assesses how the underlying disorder (BPH or prostate cancer) has affected the patient’s lifestyle. Has he been reasonably active for his age? What is his presenting urinary problem (described in his own words)? Has he experienced decreased force of urinary flow, decreased ability to initiate voiding, urgency, frequency, nocturia, dysuria, urinary retention, hematuria? Does the patient report associated problems, such as back pain, flank pain, and lower abdominal or suprapubic discomfort? If he reports such discomfort, possible causes include infection, retention, and renal colic. Has he experienced erectile dysfunction or changes in frequency or enjoyment of sexual activity? The nurse obtains further information about the patient’s family history of cancer and heart or kidney disease, including
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Testis Urethra
Sound in urethra
Hypertrophied prostate being cut
Pubis
Prostate Bladder Prostate Bladder
A
Rectum
Bladder
B
C
Urethra Urethra
Incision into prostate Bladder
Bladder Prostate
Testis Rectum
D
E
FIGURE 49-4
Prostate surgery procedures. (A) Transurethral resection (TUR). A loop of wire connected with a cutting current is rotated in the cystoscope to remove shavings of prostate at the bladder orifice. (B) Suprapubic prostatectomy. With an abdominal approach, the prostate is shelled out of its bed. (C) Perineal prostatectomy. Two retractors on the left spread the perineal incision to provide a view of the prostate. (D) Retropubic prostatectomy is performed through a low abdominal incision. Note two abdominal retractors and arrow pointing to the prostate gland. (E) Transurethral incision of prostate (TUIP) involves one or two incisions into the prostate to reduce pressure on the urethra.
hypertension. Has he lost weight? Does he appear pale? Can he raise himself out of bed and return to bed without assistance? Can he perform usual activities of daily living? This information will help in determining how soon he will return to normal activities after prostatectomy.
POSTOPERATIVE NURSING DIAGNOSES
• Acute pain related to the surgical incision, catheter placement, and bladder spasms
• Deficient knowledge about postoperative care and management
Diagnosis Based on the assessment data, the patient’s major nursing diagnoses may include the following. PREOPERATIVE NURSING DIAGNOSES • Anxiety about surgery and its outcome • Acute pain related to bladder distention • Deficient knowledge about factors related to the disorder and the treatment protocol
COLLABORATIVE PROBLEMS/POTENTIAL COMPLICATIONS Based on the assessment data, the potential complications may include the following:
• • • • •
Hemorrhage and shock Infection Deep vein thrombosis Catheter obstruction Sexual dysfunction
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Assessment and Management of Problems Related to Male Reproductive Processes
Planning and Goals The major preoperative goals for the patient may include reduced anxiety and learning about his prostate disorder and the perioperative experience. The major postoperative goals may include maintenance of fluid volume balance, relief of pain and discomfort, ability to perform self-care activities, and absence of complications.
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PREPARING THE PATIENT When the patient is scheduled for a prostatectomy, the preoperative preparation described in Chapter 18 is provided. Elastic compression stockings are applied before surgery and are particularly important for prevention of deep vein thrombosis if the patient is placed in a lithotomy position during surgery. An enema is usually administered at home the evening before surgery or the morning of surgery to prevent postoperative straining, which can induce bleeding.
Preoperative Nursing Interventions REDUCING ANXIETY The patient is frequently admitted to the hospital on the morning of surgery. Because contact with the patient may be limited before surgery, the nurse must establish communication with the patient to assess his understanding of the diagnosis and of the planned surgical procedure. The nurse clarifies the nature of the surgery and expected postoperative outcomes. In addition, the nurse familiarizes the patient with the pre- and postoperative routines and initiates measures to reduce anxiety. Because the patient may be sensitive and embarrassed discussing problems related to the genitalia and sexuality, the nurse provides privacy and establishes a trusting and professional relationship. Guilt feelings often surface if the patient falsely assumes a cause-and-effect relationship between sexual practices and his current problems. He is encouraged to verbalize his feelings and concerns. RELIEVING DISCOMFORT If discomfort is present before the day of surgery, the patient is placed on bed rest, analgesic agents are administered, and measures to relieve anxiety are initiated. If the patient is hospitalized, the nurse monitors the patient’s voiding patterns, watches for bladder distention, and assists with catheterization if indicated. An indwelling catheter is inserted if the patient has continuing urinary retention or if laboratory test results indicate azotemia (accumulation of nitrogenous waste products in the blood). The catheter can help to decompress the bladder gradually over several days, especially if the patient is elderly and hypertensive and has diminished renal function or an excessive amount of urinary retention that has existed for many weeks. For a few days after the bladder begins draining, the blood pressure may fluctuate and renal function may decline. If the patient cannot tolerate a urinary catheter, he is prepared for a cystostomy (see Chaps. 44 and 45). PROVIDING INSTRUCTION Before surgery, the nurse reviews with the patient the anatomy of the affected parts and their function in relation to the urinary and reproductive system, using diagrams and other teaching aids if indicated. This is often done either during the preadmission testing visit or in the urologist’s office. The nurse explains what will take place as the patient is prepared for diagnostic tests and then for surgery (depending on the kind of prostatectomy planned). The nurse describes the type of incision, which varies with the type of surgical approach (directly over the bladder, low on the abdomen, or in the perineal area; in the case of a transurethral procedure, no incision will be made). The patient is informed about the type of urinary drainage system that is expected, the type of anesthesia, and the recovery room procedure. The amount of information given is based on the patient’s needs and questions. Procedures expected during the immediate perioperative period are explained, questions are answered, and support is provided. In addition, the patient is instructed about postoperative use of medications for pain management.
Postoperative Nursing Interventions MAINTAINING FLUID BALANCE During the postoperative period, the patient is at risk for imbalanced fluid volume because of the irrigation of the surgical site during and after surgery. With irrigation of the urinary catheter to prevent its obstruction by blood clots, fluid may be absorbed through the open surgical site and retained, increasing the risk for excessive fluid retention, fluid imbalance, and water intoxication. The urine output and the amount of fluid used for irrigation must be closely monitored to determine if irrigation fluid is being retained and to ensure an adequate urine output. The patient also is monitored for electrolyte imbalances (ie, hyponatremia), rising blood pressure, confusion, and respiratory distress. The risk for fluid and electrolyte imbalance is increased in elderly patients with preexisting cardiovascular or respiratory disease. These signs and symptoms are documented and reported to the surgeon. RELIEVING PAIN After a prostatectomy, the patient is assisted to sit and dangle his legs over the side of the bed on the day of surgery. The next morning, he is assisted to ambulate. If pain occurs, the cause and location are determined. It may be related to the incision or may be the result of excoriation of the skin at the catheter site. It may be in the flank area, indicating a kidney problem, or it may be due to bladder spasms. Bladder irritability can initiate bleeding and result in clot formation, leading to urinary retention. Patients experiencing bladder spasms may note an urgency to void, a feeling of pressure or fullness in the bladder, and bleeding from the urethra around the catheter. Medications that relax the smooth muscles can help to ease the spasms, which can be intermittent and severe; these medications include flavoxate (Urispas) and oxybutynin (Ditropan). Warm compresses to the pubis or sitz baths may also relieve the spasms. The nurse monitors the drainage tubing and irrigates the system as prescribed to relieve any obstruction that may cause discomfort. Usually, the catheter is irrigated with 50 mL of irrigating fluid at a time. It is important to make sure that the same amount is recovered in the drainage receptacle. Securing the catheter drainage tubing to the leg or abdomen can help to decrease tension on the catheter and prevent bladder irritation. Discomfort may be caused by dressings that are too snug, saturated with drainage, or improperly placed. Analgesic agents are administered as prescribed. When ambulatory, the patient is encouraged to walk but not to sit for prolonged periods because this increases intra-abdominal pressure and the possibility of discomfort and bleeding. Prune juice and stool softeners are provided to ease bowel movements and to prevent excessive straining. An enema, if prescribed, is administered with caution to avoid rectal perforation.
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MONITORING AND MANAGING POTENTIAL COMPLICATIONS After prostatectomy, the patient is monitored for major complications such as hemorrhage, infection, deep vein thrombosis, catheter obstruction, and sexual dysfunction. Hemorrhage The immediate dangers after a prostatectomy are bleeding and hemorrhagic shock. This risk is increased with BPH because a hyperplastic prostate gland is very vascular. Bleeding may occur from the prostatic bed. Bleeding may also result in the formation of clots, which then obstruct urine flow. The drainage normally begins as reddish-pink and then clears to a light pink within 24 hours after surgery. Bright-red bleeding with increased viscosity and numerous clots usually indicates arterial bleeding. Venous blood appears darker and less viscous. Arterial hemorrhage usually requires surgical intervention (eg, suturing of bleeders or transurethral coagulation of bleeding vessels), whereas venous bleeding may be controlled by applying prescribed traction to the catheter so that the balloon holding the catheter in place applies pressure to the prostatic fossa. The surgeon applies traction by securely taping the catheter to the patient’s thigh. Nursing management includes strategies to stop the bleeding and to prevent or reverse hemorrhagic shock. If blood loss is extensive, fluids and blood component therapy may be administered. If hemorrhagic shock occurs, treatments described in Chapter 15 are initiated. Nursing interventions include close monitoring of vital signs; administering medications, intravenous fluids, and blood component therapy as prescribed; maintaining an accurate record of intake and output; and careful monitoring of drainage to ensure adequate urine flow and patency of the drainage system. The patient who experiences hemorrhage and his family are often anxious and benefit from explanations and reassurance about the event and the procedures that are performed.
physician may prescribe prophylactic (preventive) low-dose heparin therapy. The nurse assesses the patient frequently after surgery for manifestations of DVT and applies elastic compression stockings to reduce the risk for DVT and pulmonary embolism. Nursing and medical management of DVT and pulmonary embolism are detailed in Chapters 31 and 23, respectively. The patient who is receiving heparin must be closely monitored for excessive bleeding. Obstructed Catheter After a TUR, the catheter must drain well; an obstructed catheter produces distention of the prostatic capsule and resultant hemorrhage. Furosemide (Lasix) may be prescribed to promote urination and initiate postoperative diuresis, thereby helping to keep the catheter patent. The nurse observes the lower abdomen to ensure that the catheter has not become blocked. An overdistended bladder presents a distinct, rounded swelling above the pubis. The drainage bag, dressings, and incisional site are examined for bleeding. The color of the urine is noted and documented; a change in color from pink to amber indicates reduced bleeding. Blood pressure, pulse, and respirations are monitored and compared with baseline preoperative vital signs to detect hypotension. The nurse also observes the patient for restlessness, cold sweats, pallor, any drop in blood pressure, and an increasing pulse rate. Drainage of the bladder may be accomplished by gravity through a closed sterile drainage system. A three-way drainage system is useful in irrigating the bladder and preventing clot formation (Fig. 49-5). Continuous irrigation may be used with TUR. Some urologists leave an indwelling catheter attached to a dependent drainage system. Gentle irrigation of the catheter may be prescribed to remove any obstructing clots.
Infection After perineal prostatectomy, the surgeon usually changes the dressing on the first postoperative day. Further dressing changes may become the nurse’s responsibility. Careful aseptic technique is used because the possibility for infection is great. Dressings can be held in place by a double-tailed, T-binder bandage or a padded athletic supporter. The tails cross over the incision to give double thickness, and then each tail is drawn up on either side of the scrotum to the waistline and fastened. Rectal thermometers, rectal tubes, and enemas are avoided because of the risk for injury to and bleeding in the prostatic fossa. After the perineal sutures are removed, the perineum is cleansed as indicated. A heat lamp may be directed to the perineal area to promote healing. The scrotum is protected with a towel while the heat lamp is in use. Sitz baths are also used to promote healing. Urinary tract infections and epididymitis are possible complications after prostatectomy. The patient is assessed for their occurrence; if they occur, the nurse administers antibiotics as prescribed. Because the risk for infection continues after discharge from the hospital, the patient and family need to be instructed to monitor for signs and symptoms of infection (fever, chills, sweats, myalgias, dysuria, urinary frequency, and urgency). The patient and family are instructed to contact the urologist if these symptoms occur. Deep Vein Thrombosis Because patients undergoing prostatectomy have a high incidence of deep vein thrombosis (DVT) and pulmonary embolism, the
Irrigation solution
Triplelumen catheter
Bulb inflation Irrigation solution Irrigation solution Bulb inflation
Catheter drainage bag
FIGURE 49-5
A three-way system for bladder irrigation.
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Assessment and Management of Problems Related to Male Reproductive Processes
If the patient complains of pain, the tubing is examined. The drainage system is irrigated, if indicated and prescribed, to clear any obstruction. Usually, the catheter is irrigated with 50 mL of irrigating fluid at a time. The amount of fluid recovered in the drainage bag must equal the amount of fluid injected. Overdistention of the bladder is avoided because it can induce secondary hemorrhage by stretching the coagulated blood vessels in the prostatic capsule. The nurse maintains an intake and output record, including the amount of fluid used for irrigation. The drainage tube (not the catheter) is taped to the shaved inner thigh to prevent traction on the bladder. If a cystostomy catheter is in place, it is taped to the abdomen. The nurse explains the purpose of the catheter to the patient and assures him that the urge to void results from the presence of the catheter and from bladder spasms. He is cautioned not to pull on the catheter because this causes bleeding and subsequent catheter blockage, which leads to urinary retention. Complications With Catheter Removal After the catheter is removed (usually when the urine appears clear), urine may leak around the wound for several days in patients who have undergone perineal, suprapubic, and retropubic surgery. The cystostomy tube may be removed before or after the urethral catheter is removed. Some urinary incontinence may occur after catheter removal, and the patient is informed that this is likely to subside in time. Sexual Dysfunction Depending on the type of surgery, the patient may experience sexual dysfunction related to erectile dysfunction, decreased libido, and fatigue. These issues may become a concern of the patient soon after surgery or in the weeks to months during rehabilitation. Erectile dysfunction may occur following prostate surgery. Several options to restore erectile function are discussed with the patient by the surgeon or urologist. These options may include medications, surgically placed implants, or negativepressure devices. A decrease in libido may also occur following surgery and is usually related to the impact of the surgery on the man’s body. Reassurance that the usual level of libido will return following recuperation from surgery is often helpful to the patient and his partner. The patient may also experience fatigue during rehabilitation from surgery. This fatigue may also decrease his libido and alter his enjoyment of usual activities. Nursing interventions include assessing for the presence of sexual dysfunction following surgery. Providing a private and confidential environment to discuss issues of sexuality is important. The emotional challenges of prostate surgery and its consequences need to be carefully explored with the patient and his partner. Providing the opportunity to discuss these issues can be very beneficial to the patient. For patients who demonstrate significant problems adjusting to their sexual dysfunction, a referral to a sex therapist may be indicated. PROMOTING HOME AND COMMUNITY-BASED CARE Teaching Patients Self-Care The patient undergoing prostatectomy may be discharged within several days. The length of the hospital stay depends on the type of prostatectomy performed. Patients undergoing a perineal prostatectomy are hospitalized for 3 to 5 days. If a retropubic or suprapubic prostatectomy is performed, the hospital stay is 5 to 7 days. The patient and family require instructions about how to
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manage the drainage system, how to assess for complications, and how to promote recovery. Verbal and written instructions are provided about the need to maintain the drainage system and to monitor urinary output, about wound care, and about strategies to prevent complications, such as infection, bleeding, and thrombosis. They are informed about signs and symptoms that should be reported to the physician (eg, blood in urine, decreased urine output, fever, change in wound drainage, calf tenderness). As the patient recovers and drainage tubes are removed, he may become discouraged and depressed because he cannot regain bladder control immediately. Moreover, urinary frequency and burning may occur after the catheter is removed. Teaching the following exercises may help the patient regain urinary control:
• Tense the perineal muscles by pressing the buttocks together; •
hold this position; relax. This exercise can be performed 10 to 20 times each hour while sitting or standing. Try to interrupt the urinary stream after starting to void; wait a few seconds and then continue to void.
Perineal exercises should continue until the patient gains full urinary control. The patient is instructed to urinate as soon as he feels the first urge to do so. It is important for the patient to know that regaining urinary control is a gradual process; he may continue to “dribble” after being discharged from the hospital, but the dribbling should gradually diminish (within up to 1 year). Lining underwear with absorbent pads can help to minimize embarrassing stains on clothing. The urine may be cloudy for several weeks after surgery but should clear as the prostate area heals. While the prostatic fossa heals (6 to 8 weeks), the patient should avoid activities that produce Valsalva effects (straining at stool, heavy lifting) because this increases venous pressure and may produce hematuria. He should avoid long motor trips and strenuous exercise, which increase the tendency to bleed. He should also know that spicy foods, alcohol, and coffee may cause bladder discomfort. The patient is cautioned to drink enough fluids to avoid dehydration, which increases the tendency for a blood clot to form and obstruct the flow of urine. Signs of complications, such as bleeding, passage of blood clots, a decrease in the urinary stream, urinary retention, or urinary tract infection symptoms, should be reported to the physician (Chart 49-3). Continuing Care Referral for home care may be indicated if the patient is elderly or has other health problems, if the patient and family cannot provide care in the home, or if the patient lives alone without available supports. The home care nurse assesses the patient’s physical status (cardiovascular and respiratory status, fluid and nutritional status, patency of the urinary drainage system, wound and nutritional status) and provides catheter and wound care, if indicated. The nurse reinforces previous teaching and assesses the ability of the patient and family to manage required care. The home care nurse encourages the patient to ambulate and to carry out perineal exercises as prescribed. The patient may need to be reminded that return of bladder control may take time. The patient is reminded about the importance of participating in routine health screening and other health promotion activities. If the prostatectomy was performed to treat prostate cancer, the patient and family are also instructed about the importance of follow-up and monitoring with the physician.
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Chart 49-3 Home Care Checklist • Postprostatectomy Care At the completion of the home care instruction, the patient or caregiver will be able to: • Demonstrate appropriate measures to control postoperative pain and discomfort • Demonstrate appropriate care of urinary catheter and collection receptacle • Demonstrate appropriate wound care • Demonstrate performance of perineal muscle exercises to facilitate bladder control • Demonstrate increased activity and ambulation • Identify activities to avoid, such as lifting heavy objects • Identify signs and symptoms of complications that should be reported to surgeon
Evaluation EXPECTED PREOPERATIVE PATIENT OUTCOMES Expected preoperative patient outcomes may include: 1. Demonstrates reduced anxiety 2. States that pain and discomfort are decreased 3. Relates understanding of the surgical procedure and postoperative course and practices perineal muscle exercises and other techniques useful in facilitating bladder control EXPECTED POSTOPERATIVE PATIENT OUTCOMES Expected postoperative patient outcomes may include: 1. Relates relief of discomfort 2. Exhibits fluid and electrolyte balance a. Irrigation fluid and urinary output are within parameters determined by surgeon. b. Experiences no signs or symptoms of fluid retention 3. Participates in self-care measures a. Increases activity and ambulation daily b. Produces urine output within normal ranges and consistent with intake c. Performs perineal exercises and interrupts urinary stream to promote bladder control d. Avoids straining and lifting heavy objects 4. Is free of complications a. Maintains vital signs within normal limits b. Exhibits wound healing, without signs of inflammation or hemorrhage c. Maintains acceptable level of urinary elimination d. Maintains optimal drainage of catheter and other drainage tubes e. Reports understanding of changes in sexual function
Conditions Affecting the Testes and Adjacent Structures UNDESCENDED TESTIS (CRYPTORCHIDISM) Cryptorchidism is a congenital condition characterized by failure of one or both of the testes to descend into the scrotum. One or both testes may be absent. The testis may be located in the abdominal cavity or inguinal canal. If the testis does not descend as the boy matures, a surgical procedure known as orchiopexy is performed to position it properly. An incision is made over the in-
Patient
Caregiver
✓ ✓ ✓ ✓ ✓ ✓ ✓
✓ ✓ ✓
✓ ✓
guinal canal, and the testis is brought down and anchored in the scrotum.
ORCHITIS Orchitis is an inflammation of the testes (testicular congestion) caused by pyogenic, viral, spirochetal, parasitic, traumatic, chemical, or unknown factors. Mumps is one such factor. Mumps vaccination is recommended for postpubertal men who have not been infected. When postpubertal men contract mumps, about one in five develops some form of orchitis 4 to 7 days after the jaw and neck swell. The testis may show some atrophy. In the past, sterility and impotence often resulted. Today, a man who has never had mumps and who is exposed to the disease receives gamma-globulin immediately; the disease is likely to be less severe, with minimal or no complications.
Medical Management If the cause of orchitis is bacterial, viral, or fungal, therapy is directed at the specific infecting organism. Rest, elevation of the scrotum, ice packs to reduce scrotal edema, antibiotics, analgesic agents, and anti-inflammatory medications are recommended.
EPIDIDYMITIS Epididymitis is an infection of the epididymis that usually descends from an infected prostate or urinary tract. It may also develop as a complication of gonorrhea. In men younger than age 35, the major cause of epididymitis is Chlamydia trachomatis. The infection passes upward through the urethra and the ejaculatory duct and then along the vas deferens to the epididymis. The patient complains of unilateral pain and soreness in the inguinal canal along the course of the vas deferens and then develops pain and swelling in the scrotum and the groin. The epididymis becomes swollen and extremely painful; the patient’s temperature is elevated. The urine may contain pus (pyuria) and bacteria (bacteriuria), and the patient may experience chills and fever.
Medical Management If the patient is seen within the first 24 hours after onset of pain, the spermatic cord may be infiltrated with a local anesthetic agent to relieve pain. If the epididymitis is from a chlamydial infection, the patient and his sexual partner must be treated with antibiotics. The patient is observed for abscess formation as well. If no
Chapter 49
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improvement occurs within 2 weeks, an underlying testicular tumor should be considered. An epididymectomy (excision of the epididymis from the testis) may be performed for patients with recurrent, incapacitating episodes of epididymitis or for those with chronic, painful conditions. With long-term epididymitis, the passage of sperm may be obstructed. If the obstruction is bilateral, infertility may result.
Nursing Management The patient is placed on bed rest, and the scrotum is elevated with a scrotal bridge or folded towel to prevent traction on the spermatic cord and to promote venous drainage and relieve pain. Antimicrobial agents are administered as prescribed until the acute inflammation subsides. Intermittent cold compresses to the scrotum may help ease the pain. Later, local heat or sitz baths may help resolve the inflammation. Analgesic medications are administered for pain relief as prescribed. The nurse instructs the patient to avoid straining, lifting, and sexual stimulation until the infection is under control. He should continue taking analgesic agents and antibiotics as prescribed and using ice packs if necessary to relieve discomfort. He needs to know that it may take 4 weeks or longer for the epididymis to return to normal.
TESTICULAR CANCER Testicular cancer is the most common cancer in men 15 to 35 years of age. Although testicular cancer occurs most often between the ages of 15 and 40, it can occur in males of any age. It is a highly treatable and usually curable form of cancer. An estimated 7,500 men are diagnosed with testicular cancer each year, and approximately 400 die from testicular cancer annually (American Cancer Society, 2002). The testicles contain several types of cells, each of which may develop into one or more types of cancer. The type of cancer determines the appropriate treatment and affects the prognosis. Testicular cancers are classified as germinal or nongerminal (stromal); secondary testicular cancers may also occur.
Germinal Tumors Over 90% of all cancers of the testicle are germinal; geminal tumors may be further classified as seminomas or nonseminomas. About half of all geminal tumors are seminomas, or tumors that develop from the sperm-producing cells of the testes. Nonseminoma germinal cell tumors tend to develop earlier in life than seminomas, usually occurring in men in their 20s. Examples of nonseminomas include teratocarcinomas, choriocarcinomas, yolk sac carcinomas, and embryonal carcinomas. Seminomas tend to remain localized, whereas nonseminomatous tumors grow quickly.
Nongerminal Tumors Testicular cancer may also develop in the supportive and hormoneproducing tissues, or stroma, of the testicles. These tumors account for about 4% of testicular tumors in adults and 20% of testicular tumors in children. The two main types of stromal tumors are Leydig cell tumors and Sertoli cell tumors. Although these tumors infrequently spread beyond the testicle, a small number of these tumors metastasize and tend to be resistant to chemotherapy and radiation therapy.
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Secondary Testicular Tumors Secondary testicular tumors are those that have metastasized to the testicle from other organs. Lymphoma is the most common cause of secondary testicular cancer. Cancers may also spread to the testicles from the prostate gland, lung, skin (melanoma), kidney, and other organs. The prognosis for these cancers is usually poor because these cancers generally also spread to other organs. Treatment depends on the specific type of cancer (American Cancer Society, 2002).
Risk Factors The risk for testicular cancer is several times greater in men with any type of undescended testis than in the general population (Bosl, Bajorin, Scheinfeld et al., 2001). Risk factors include a family history of testicular cancer and cancer of one testicle, which increases the risk for the other testicle. Race and ethnicity have been identified as risk factors: Caucasian American men have a five times greater risk than that of African American men and more than double the risk of Asian American men. Occupational hazards, including exposure to chemicals encountered in mining, oil and gas production, and leather processing, have been suggested as possible risk factors. Prenatal exposure to DES may also be a risk factor, but evidence is not strong (American Cancer Society, 2002). Vasectomy, once considered a possible risk factor, has been shown in recent studies not to be a risk factor (Cox, Sneyd, Paul et al., 2002).
Clinical Manifestations The symptoms appear gradually, with a mass or lump on the testicle and generally painless enlargement of the testis. The patient may complain of heaviness in the scrotum, inguinal area, or lower abdomen. Backache (from retroperitoneal node extension), abdominal pain, weight loss, and general weakness may result from metastasis. Enlargement of the testis without pain is a significant diagnostic finding. Testicular tumors tend to metastasize early, spreading from the testis to the lymph nodes in the retroperitoneum and to the lungs.
Assessment and Diagnostic Findings Monthly testicular self-examinations (TSEs) are effective in detecting testicular cancer (Chart 49-4). Teaching men of all ages to perform TSE is an important health promotion intervention for early detection of testicular cancer. Since testicular cancer occurs most often in young adults, testicular self-examination should begin during adolescence. Human chorionic gonadotropin and alpha-fetoprotein are tumor markers that may be elevated in patients with testicular cancer. (Tumor markers are substances synthesized by the tumor cells and released into the circulation in abnormal amounts.) Tumor marker levels in the blood are used for diagnosis, staging, and monitoring the response to treatment. Other diagnostic tests include intravenous urography to detect any ureteral deviation caused by a tumor mass; lymphangiography to assess the extent of tumor spread to the lymphatic system; ultrasound to determine the presence and size of the testicular mass; and CT scan of the chest, abdomen, and pelvis to determine the extent of the disease in the lungs, retroperitoneum, and pelvis. Microscopic analysis of tissue is the only definitive way to determine if
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Chart 49-4
• PATIENT EDUCATION Testicular Self-Examination Testicular self-examination (TSE) is to be performed once a month. The test is neither difficult nor timeconsuming. A convenient time is usually after a warm bath or shower when the scrotum is more relaxed.
B C Lump
A Spermatic cord
1. Use both hands to palpate the testis. The normal testicle is smooth and uniform in consistency. 2. With the index and middle fingers under the testis and the thumb on top, roll the testis gently in a horizontal plane between the thumb and fingers (A). 3. Feel for any evidence of a small lump or abnormality. 4. Follow the same procedure and palpate upward along the testis (B).
cancer is present but is usually performed at the time of surgery rather than as a part of the diagnostic workup to reduce the risk of promoting spread of the cancer (American Cancer Society, 2000).
Medical Management Testicular cancer is one of the most curable solid tumors. The goals of management are to eradicate the disease and achieve a cure. Treatment selection is based on the cell type and the anatomic extent of the disease. The testis is removed by orchiectomy through an inguinal incision with a high ligation of the spermatic cord. A gel-filled prosthesis can be implanted. After unilateral orchiectomy for testicular cancer, most patients experience no impairment of endocrine function. Other patients, however, have decreased hormonal levels, suggesting that the unaffected testis is not functioning at normal levels. Retroperitoneal lymph node dissection to prevent lymphatic spread of the cancer may be performed after orchiectomy. Although libido and orgasm are usually unimpaired after retroperitoneal lymph node
5. Locate and palpate the epididymis (C), a cord-like structure on the top and back of the testicle that stores and transports sperm. Also locate and palpate the spermatic cord. 6. Repeat the examination for the other testis, epididymis, and spermatic cord. It is normal to find that one testis is larger than the other. 7. If you find any evidence of a small, pea-like lump or if the testis is swollen (possibly from an infection or tumor), consult your physician.
dissection, the patient may develop ejaculatory dysfunction with resultant infertility. Thus, sperm banking before surgery may be considered (Agarwa, 2000; Zapzalka et al., 1999). Postoperative irradiation of the lymph nodes from the diaphragm to the iliac region is used in treating seminomas. Radiation is delivered only to the affected side; the other testis is shielded from radiation to preserve fertility. Radiation is also used for patients whose disease does not respond to chemotherapy or for whom lymph node surgery is not recommended. Lymphangiograms and CT scans are used to determine spread of the disease to the lymph nodes. Testicular carcinomas are highly responsive to chemotherapy. (Bosl et al., 2001) Chemotherapy with cisplatin-based regimens results in a high percentage of complete remissions. Good results may be obtained by combining different types of treatment, including surgery, radiation therapy, and chemotherapy. Even with disseminated testicular cancer, the prognosis is favorable, and the disease is probably curable because of advances in diagnosis and treatment.
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A patient with a history of one testicular tumor has a greater chance of developing subsequent tumors. Follow-up studies include chest x-rays, excretory urography, radioimmunoassay of human chorionic gonadotropins and alpha-fetoprotein levels, and examination of lymph nodes to detect recurrent malignancy. Long-term side effects associated with treatments for testicular cancer include kidney damage, hearing problems, gonadal damage, neurological changes, and rarely secondary cancers (Kollmannsberger, Kuzcyk, Mayer et al., 1999). Research on treatment regimens with less toxicity and the use of cytoprotectants is ongoing.
Nursing Management Nursing management includes assessment of the patient’s physical and psychological status and monitoring the patient for response to and possible effects of surgery, chemotherapy, and radiation therapy (see Chap. 16). Pre- and postoperative care is described in Chapters 18 and 19, respectively. In addition, because the patient may have difficulty coping with his condition, issues related to body image and sexuality are addressed. He needs encouragement to maintain a positive attitude during what may be a long course of therapy. He also needs to know that radiation therapy will not necessarily prevent him from fathering children, nor does unilateral excision of a testis necessarily decrease virility. The nurse reminds the patient about the importance of performing TSE and keeping follow-up appointments with the physician. The patient is also encouraged to participate in health promotion and health screening activities.
HYDROCELE A hydrocele is a collection of fluid, generally in the tunica vaginalis of the testis, although it may also collect within the spermatic cord. The tunica vaginalis becomes widely distended with fluid. Hydrocele can be differentiated from a hernia by transillumination; a hydrocele transmits light, whereas a hernia does not. Hydrocele may be acute or chronic. Acute hydrocele may occur in association with acute infectious diseases of the epididymis or as a result of local injury or systemic infectious diseases, such as mumps. The cause of chronic hydrocele is unknown. Usually, therapy is not required. Treatment is necessary only if the hydrocele becomes tense and compromises testicular circulation or if the scrotal mass becomes large, uncomfortable, or embarrassing. In the surgical treatment of hydrocele, an incision is made through the wall of the scrotum down to the distended tunica vaginalis. The sac is resected or, after being opened, is sutured together to collapse the wall. Postoperatively, the patient wears an athletic supporter for comfort and support. The major complication is hematoma in the loose scrotal tissues.
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may be applied to the scrotum for the first few hours after surgery to relieve edema. The patient then wears a scrotal supporter.
VASECTOMY Vasectomy, or male sterilization, is the ligation and transection of part of the vas deferens, with or without removal of a segment of the vas deferens. To prevent the passage of the sperm from the testes, the vas deferens is exposed through a surgical opening in the scrotum or a puncture using a sharp, curved hemostat (Fig. 49-6). The severed ends are occluded with ligatures or clips, or the lumen of each vas deferens is sealed by cautery. The spermatozoa, which are manufactured in the testes, cannot travel up the vas deferens after this surgery. Because seminal fluid is manufactured predominantly in the seminal vesicles and prostate gland, which are unaffected by vasectomy, no noticeable decrease occurs in the amount of ejaculate even though it contains no spermatozoa. Because the sperm cells have no exit, they are resorbed into the body. This procedure has no effect on sexual potency, erection, ejaculation, or production of male hormones and provides no protection against sexually transmitted diseases. Couples who were worried about pregnancy resulting from contraceptive failure often report a decrease in concern and an increase in spontaneous sexual arousal after vasectomy. Concise and factual preoperative explanations may minimize or relieve the patient’s concerns related to masculinity. Although a relationship between vasectomy and autoimmune disorders and prostatic cancer has been suggested, there is no clinical evidence of either. The patient is advised that he will be sterile but that potency will not be altered after a bilateral vasectomy. As with any surgical procedure, a surgical consent form must be signed. On rare occasions, a spontaneous reanastomosis of the vas deferens occurs, making it possible to impregnate a partner. Complications of vasectomy include scrotal ecchymoses and swelling, superficial wound infection, vasitis (inflammation of the vas deferens), epididymitis or epididymo-orchitis, hematomas, and spermatic granuloma. A spermatic granuloma is an inflammatory response to the collection of sperm leaking into the scrotum from the severed end of the proximal vas deferens. This can initiate recanalization of the vas deferens, making pregnancy possible.
B
VARICOCELE A varicocele is an abnormal dilation of the veins of the pampiniform venous plexus in the scrotum (the network of veins from the testis and the epididymis that constitute part of the spermatic cord). Varicoceles usually occur in the veins on the upper portion of the left testicle in adults. In some men, a varicocele has been associated with infertility. Few, if any, subjective symptoms may be produced by the enlarged spermatic vein, and no treatment is required unless fertility is a concern. Symptomatic varicocele (pain, tenderness, and discomfort in the inguinal region) is corrected surgically by ligating the external spermatic vein at the inguinal area. An ice pack
C A
FIGURE 49-6 A vasectomy is a resection of the vas deferens to prevent passage of sperm from the testes to the urethra during ejaculation. (A) An incision or small puncture is made to expose the vas deferens. (B) The vas deferens is isolated and severed. (C) The severed ends are occluded with ligatures or clips, or the lumen of each vas is sealed by electrocautery and the incision is sutured closed. (Suturing may not be required if a puncture approach has been used.)
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Nursing Management Ice bags are applied intermittently to the scrotum for several hours after surgery to reduce swelling and to relieve discomfort. The nurse advises the patient to wear cotton, Jockey-type briefs for added comfort and support. He may become greatly concerned about the discoloration of the scrotal skin and superficial swelling. These are temporary conditions that occur frequently after vasectomy and may be relieved by sitz baths. Sexual intercourse may be resumed as desired, although fertility remains for a varying time after vasectomy until the spermatozoa stored distal to the severed vas deferens have been evacuated. Other methods of contraception should be used until infertility is confirmed by an examination of ejaculate. Some physicians examine a specimen 4 weeks after the vasectomy to determine sterility; others examine two consecutive specimens 1 month apart; and still others consider a patient sterile after 36 ejaculations.
edema, cannot be returned to its usual position (covering the glans). Paraphimosis is treated by firmly compressing the glans to reduce its size and then pushing the glans back while simultaneously moving the prepuce forward (manual reduction). Circumcision is usually indicated after the inflammation and edema subside.
CANCER OF THE PENIS
Microsurgical techniques are used to reverse a vasectomy (vasovasostomy), thus restoring patency to the vas deferens. Many men have sperm in their ejaculate after a reversal, and 40% to 75% can impregnate a partner.
Penile cancer occurs in men older than age 60 and represents about 0.5% of malignancies in men in the United States (Stadler, Vogelzang, Elwell & Jones, 2000). In some countries, however, the incidence is 10% to 12%. Since most penile cancers occur in uncircumcised men, it has been suggested that the etiology of this cancer may be the irritative effect of smegma and poor hygiene. However, the “protective” effect of circumcision is seen only in males who are circumcised in the neonatal period; circumcision that occurs at puberty or after does not confer the same benefit (Herr et al., 2001). Cancer of the penis appears on the skin of the penis as a painless, wartlike growth or ulcer. Cancer of the penis can involve the glans, the coronal sulcus under the prepuce, the corporal bodies, the urethra, and regional or distant lymph nodes. Bowen’s disease is a form of squamous cell carcinoma in situ of the penile shaft. Typically, a man delays seeking treatment for more than a year, probably because of guilt, embarrassment, or ignorance.
Banking Sperm
Prevention
Storing fertile semen in a sperm bank before a vasectomy is an option for men who face an unforeseen life event that may cause them to want to father a child at a later time. In addition, if a man is about to undergo a procedure or treatment (eg, radiation therapy to the pelvis or chemotherapy) that may affect his fertility, sperm banking may be considered. This procedure usually requires several visits to the facility where the sperm is stored under hypothermic conditions. The semen is produced by masturbation and collected in a sterile container for storage.
Circumcision in infancy almost eliminates the possibility of penile cancer because chronic irritation and inflammation of the glans penis predispose to penile tumors (Herr et al., 2001; Pettaway & Dinney, 2001; Schoen et al., 2000). In uncircumcised men, personal hygiene is an important preventive measure.
Vasovasostomy (Sterilization Reversal)
Conditions Affecting the Penis HYPOSPADIAS AND EPISPADIAS Hypospadias and epispadias are congenital anomalies of the urethral opening. In hypospadias, the urethral opening is a groove on the underside of the penis. In epispadias, the urethral opening is on the dorsum. These anatomic abnormalities may be repaired by various types of plastic surgery, usually when the boy is very young.
PHIMOSIS Phimosis, a condition in which the foreskin is constricted so that it cannot be retracted over the glans, can occur congenitally or from inflammation and edema. With the trend away from routine circumcision of newborns, early instruction should be given about cleansing the prepuce. If the preputial area is not cleaned, normal secretions accumulate, causing inflammation (balanitis), which can lead to adhesions and fibrosis. The thickened secretions become encrusted with urinary salts and calcify, forming calculi in the prepuce. In elderly men, penile carcinoma may develop. Phimosis is corrected by circumcision (see later discussion). Paraphimosis is a condition in which the foreskin is retracted behind the glans and, because of narrowness and subsequent
Medical Management Smaller lesions involving only the skin may be controlled by excision (Herr et al., 2001). Topical chemotherapy with 5-fluorouracil cream is an option in selected patients. Radiation therapy is used to treat small squamous cell carcinomas of the penis or for palliation in advanced tumors or lymph node metastasis. Partial penectomy (removal of the penis) is preferred to total penectomy if possible; about 40% of patients can then participate in sexual intercourse and stand for urination. The shaft of the penis can still respond to sexual arousal with an erection and has the sensory capacity for orgasm and ejaculation. Total penectomy is indicated when the tumor is not amenable to conservative treatment. After a total penectomy, the patient may still experience orgasm with stimulation of the perineum and scrotal area.
PRIAPISM Priapism is an uncontrolled, persistent erection of the penis that causes the penis to become large, hard, and painful. It occurs from either neural or vascular causes, including sickle cell thrombosis, leukemic cell infiltration, spinal cord tumors or injury, and tumor invasion of the penis or its vessels. It may also occur with use of medications that affect the central nervous system, antihypertensive agents, antidepressant medications, and substances injected into the penis to treat erectile dysfunction. This condition may result in gangrene and often results in impotence, whether treated or not. Priapism is a urologic emergency. The goal of therapy is to improve venous drainage of the corpora cavernosa to prevent is-
Chapter 49
Assessment and Management of Problems Related to Male Reproductive Processes
chemia, fibrosis, and impotence. The initial treatment is directed at relieving the erection and includes bed rest and sedation. The corpora may be irrigated with an anticoagulant, which allows stagnant blood to be aspirated. Shunting procedures to divert the blood from the turgid corpora cavernosa to the venous system (corpora cavernosa–saphenous vein shunt) or into the corpus spongiosum–glans penis compartment may be attempted.
PEYRONIE’S DISEASE Peyronie’s disease involves the buildup of fibrous plaques in the sheath of the corpus cavernosum. These plaques are not visible when the penis is relaxed. When erect, however, curvature of the penis occurs that can be painful and can make sexual intercourse difficult or impossible. Peyronie’s disease primarily occurs in middle-aged and older men. Although the plaques may shrink over time, surgical removal of the plaques may be necessary.
URETHRAL STRICTURE Urethral stricture is a condition in which a section of the urethra is narrowed. It can occur congenitally or from a scar along the urethra. Traumatic injury to the urethra (for example, from instrumentation or infections) can result in strictures. Treatment involves dilation of the urethra or, in severe cases, urethrotomy (surgical removal of the stricture).
CIRCUMCISION Circumcision is the excision of the foreskin, or prepuce, of the glans penis. It is usually performed in infancy. In adults, it is part of the treatment for phimosis, paraphimosis, and recurrent infections of the glans and foreskin and may be performed at the personal desire of the patient. Postoperatively, a petrolatum (Vaseline) gauze dressing is applied and changed as indicated. The patient is observed for bleeding. Because considerable pain may occur after circumcision, analgesic agents are administered as needed.
?
Critical Thinking Exercises
1.
During a community health fair, you are approached by a 49-year-old African American man who asks you about his risks for prostate cancer. Develop a plan to address this issue with him at the health fair and provide the rationale for your plan. How would your responses differ if you saw the patient during an office visit to follow up an elevated PSA test result?
2.
One of your patients, a 44-year-old man with multiple sclerosis, asks you about Viagra. What information would you give him about Viagra, and what teaching approach would you use? How would your approach differ if your patient were a 56-year-old man with long-standing diabetes? If your patient were a 68-year-old man with coronary artery disease?
3.
You are caring for two patients who have undergone prostatectomy. One has had surgery to treat BPH and the other to treat prostate cancer. How would your care differ for these two patients? How would the patient’s underlying disorder alter your hospital care and your discharge planning?
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4.
A 34-year-old man is seeking treatment for an STD. When you are obtaining the health history, he reports that this is his fifth or sixth episode of STD. In addition to assisting with medical management and follow-up, what other interventions would you consider for this patient? What strategies would you suggest to him to reduce his risk for subsequent STDs and the risk of transmitting an STD to his sexual partner? How would your teaching differ if the patient revealed that he had sex with men only?
5.
During a routine pre-employment physical examination, a 23-year-old man is found to have a mass in the left testicle. He dismisses its significance, saying that it is nothing to be concerned about and that he cannot interrupt his plans to have it evaluated, as he will be getting married in a month and beginning a new job. What information would you provide to the patient at this time? What explanation would you give to him about the evaluation of the testicular mass and possible outcomes?
REFERENCES AND SELECTED READINGS Books American Cancer Society (2002). Cancer facts and figures 2002. Atlanta: American Cancer Society. Annon, J. S. (1976). Behavioral treatment of sexual problems: Brief therapy. Hagerstown, MD: Harper & Row. Bosl, G. J., Bajorin, D. F., Scheinfeld, J., et al. (2001). Cancer of the testis. In V. T. DeVita, S. Hellman, & S. A. Rosenberg (Eds.). Cancer: Principles and practice of oncology (6th ed.). Philadelphia: Lippincott Williams & Wilkins. Bruner, D. W., & Iwamoto, R. R. (1999). Altered sexual health. In C. H. Yarbro, M. H. Frogge, & M. Goodman (Eds.). Cancer symptom management (2nd ed.). Boston: Jones & Bartlett. Campbell, M. F., Retik, A. B., Vaughn, E. D., & Walsh, P. C. (Eds.). (1998). Campbell’s urology (7th ed.). Philadelphia: W. B. Saunders. Carroll, P. R., Lee, K. L., Fuks, Z. Y., & Kantoff, P. W. (2001). Cancer of the prostate. In V. T. DeVita, S. Hellman, & S. A. Rosenberg (Eds.). Cancer: Principles and practice of oncology (6th ed.). Philadelphia: Lippincott Williams & Wilkins. Dodd, P. M., & Kelly, W. K. (2001). Testicular cancer. In R. E. Lenhard, R. T. Osteen, & T. Gansler (Eds.). Clinical oncology. Atlanta: American Cancer Society. Ducharme, S. H., & Gill, K. M. (1997). Management of other male sexual dysfunctions. In M. L. Sipski & C. J. Alexander. Sexual function in people with disability and chronic illness. Gaithersburg, MD: Aspen. Fosså, S. D., Aass, N., Roghavan, D., & Vogelzang, N. J. (2000). Late toxicity after chemotherapy of germ cell testis cancer. In N. J. Vogelzang, P. T. Scardino, W. U. Shipley & D. S. Coffey (Eds.). Comprehensive textbook of genitourinary oncology (2d ed.) Philadelphia: Lippincott Williams & Wilkins. Greene, F. L., Page, D. L., Fleming, I. D., et al. (2002). AJCC cancer staging manual (6th ed.). New York: Springer-Verlag. Herr, H. W., Dalbagni, G., Bajorin, D. F., & Shipley, W. U. (2001). Cancer of the urethra and penis. In V. T. DeVita, S. Hellman & S. A. Rosenberg (Eds.). Cancer: Principles and practice of oncology (6th ed.). Philadelphia: Lippincott Williams & Wilkins. Hinman, F. (Ed.). (1998). Atlas of urologic surgery (2nd ed.). Philadelphia: W. B. Saunders. Kantoff, P. W., Carroll, A. V., & D’Amico, A. V. (Eds.) (2002). Prostate cancer: Principles and practice. Philadelphia: Lippincott Williams & Wilkins. Kelly, W. K., & Dodd, P. M. (2001). Prostate cancer. In R. E. Lenhard, R. T. Osteen & T. Gansler (Eds.). Clinical oncology. Atlanta: American Cancer Society.
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Lepor, H. (1998). Natural history, evaluation, and nonsurgical management of benign prostatic hyperplasia. In M. F. Campbell, A. B. Retik, E. D. Vaughn & P. C. Walsh (Eds.). Campbell’s urology (7th ed.). Philadelphia: W. B. Saunders. Leung, A. C., Kadmon, D., & Fair, W. (2000). Prevention of prostate cancer. In N. J. Vogelzang, P. T. Scardino, W. U. Shipley & D. S. Coffey (Eds.). Comprehensive textbook of genitourinary oncology (2d ed.) Philadelphia: Lippincott Williams & Wilkins. McCullough, D. L. (1998). Minimally invasive treatment of benign prostatic hyperplasia. In M. F. Campbell, A. B. Retik, E. D. Vaughn, & P. C. Walsh (Eds.). Campbell’s urology (7th ed.). Philadelphia: W. B. Saunders. McConnell, J. D. (1998). Epidemiology, etiology, pathophysiology, and diagnosis of benign prostatic hyperplasia. In M. F. Campbell, A. B. Retik, E. D. Vaughn, & P. C. Walsh (Eds.). Campbell’s urology (7th ed.). Philadelphia: W. B. Saunders. Mebust, W. K. (1998). Transurethral surgery. In M. F. Campbell, A. B. Retik, E. D. Vaughn & P. C. Walsh (Eds.). Campbell’s urology (7th ed.). Philadelphia: W. B. Saunders. Narayan, P., Yu, K. K., Patel, M., & Hricak, H. (2000) Imaging in prostate cancer. In N. J. Vogelzang, P. T. Scardino, W. U. Shipley & D. S. Coffey (Eds.). Comprehensive textbook of genitourinary oncology (2d ed.) Philadelphia: Lippincott Williams & Wilkins. Oliver, R. T. D. (2000). Epidemiology of testis cancer: A clinical perspective. In N. J. Vogelzang, P. T. Scardino, W. U. Shipley & D. S. Coffey (Eds.). Comprehensive textbook of genitourinary oncology (2d ed.) Philadelphia: Lippincott Williams & Wilkins. Pettaway, C. A., & Dinney, C. P. N. (2001). Penile and urethral cancer. In R. E. Lenhard, R. T. Osteen & T. Gansler (Eds.). Clinical oncology. Atlanta: American Cancer Society. Sipski, M. L., & Alexander, C. J. (Eds.). (1997). Sexual function in people with disability and chronic illness: A health professional’s guide. Gaithersburg, MD: Aspen. Stadler, W. M., Vogelzang, N. J., Elwell, C. M., & Jones, W. G. (2000) Penile cancer: Overview. In N. J. Vogelzang, P. T. Scardino, W. U. Shipley & D. S. Coffey (Eds.). Comprehensive textbook of genitourinary oncology (2d ed.) Philadelphia: Lippincott Williams & Wilkins. Thomas, G. M., & Williams, S. D. (1998). Testis. In C. A. Perez & L. W. Brady (Eds.). Principles and practices of radiation oncology (3rd ed.). Philadelphia: Lippincott-Raven. U.S. Surgeon General (2001). U.S. Surgeon General’s call to action to promote sexual health and responsible sexual behavior. Washington DC: United States Public Health Service.
Journals Asterisks indicate nursing research articles. General Centers of Disease Control and Prevention (2000). CDC statement on study results of products containing nonoxynol-9. Journal of the American Medical Association, 284(11), 1376. Centers for Disease Control and Prevention (CDC). (2002). Sexually transmitted diseases treatment guidelines, 2002. MMWR-Morbidity and Mortality Weekly Report, 51(RR-6), 1–85. Eckert, J. K., & Rubinstein, R. L. (1999). Older men’s health: Sociocultural and ecological perspectives. Medical Clinics of North America, 83(5), 1151. Johnson, T. M. II, & Ouslander, J. G. (1999). Urinary incontinence in the older man. Medical Clinics of North America, 83(5), 1247. Millon-Underwood, S., & Sanders, E. (1990). Factors contributing to health promotion behaviors among African-American men. Oncology Nursing Forum, 17(5), 707–712. Schoen, E. J., Oehrli, M., Colby, C., & Machin, G. (2000) The highly protective effect of newborn circumcision against invasive penile cancer. Pediatrics, 105(3), E36. Van Damme, L. (2000). Advances in topical microbicides. Presented at the XIII International AIDS Conference, July 9–14, 2000, Durban, South Africa.
Watson, J., & Fried, L. P. (1999). Frailty and the older man. Medical Clinics of North America, 83(5), 1173. Assessment of Function and Dysfunction of Male Reproductive System Bakshi, S., & Miller, D. K. (1999). Assessment of the aging man. Medical Clinics of North America, 83(5), 1131–1147. Hughes, M. K. (2000). Sexuality and the cancer survivor: A silent coexistence. Cancer Nursing, 23(6), 477–482. Penson, R. T., Gallagher, J., Gioiella, M. E., et al. (2000). Sexuality and cancer: Conversation comfort zone. Oncologist, 5(4), 336–344. Eid, J. F. (2000). Sildenafil citrate: Current clinical experience. International Journal of Impotence Research, 12Suppl 4, S62-S66. Goldstein, I., Lue, T. F., Padma-Nathan, H., et al. (1998). Oral sildenafil in the treatment of erectile dysfunction. Sildenafil Study Group. New England Journal of Medicine, 338(20), 1397–1404. Kaiser, F. E. (1999). Erectile dysfunction in the aging man. Medical Clinics of North America, 83(5), 1267. Klingman, L. (1999). Assessing the male genitalia. American Journal of Nursing, 99(7), 47–50. Korenman, S. G. (1998). New insights into erectile dysfunction: A practical approach. American Journal of Medicine, 105(2), 135–144. Lue, T. F. (2000). Erectile dysfunction. New England Journal of Medicine, 342(24), 1802–1813. National Institutes of Health Consensus Development Panel on Impotence. (1993). Impotence. Journal of the American Medical Association, 270(1), 83–90. Padma-Nathan, H., Hellstrom W. J., Kaiser, F. E., et al. (1997). Treatment of men with erectile dysfunction with transurethral alprostadil. Medicated Urethral System for Erection (MUSE) Study Group. New England Journal of Medicine, 336(1), 1–7. Sundaram, C. P., Thomas, W., Pryor, L. E., et al. (1997). Long-term follow-up of patients receiving injection therapy for erectile dysfunction.Urology, 49(6), 932–935. Benign Prostatic Hyperplasia Barry, M. J., Fowler, F. J. Jr., Bin, L., et al. (1997). The natural history of patients with benign prostatic hyperplasia as diagnosed by North American urologists. Journal of Urology, 157(1), 10–15. Gerber, G. S. (2000). Saw palmetto for the treatment of men with lower urinary tract symptoms. Journal of Urology, 163(5), 1408–1412. (1999) Saw palmetto for benign prostatic hyperplasia. Medical Letter on Drugs and Therapeutics, 41(1046), 18. Marks, L. S., Partin, A. W., Epstein, J. L., et al. (2000). Effects of a saw palmetto herbal blend in men with symptomatic benign prostatic hyperplasia. Journal of Urology, 163(5), 1451–1456. Medina, J. J., Parra, R. O., & Moore, R. G. (1999). Benign prostatic hyperplasia (the aging prostate). Medical Clinics of North America, 83(5), 1213. Ramsey, E. W., Miller, P. D., Parsons, K., et al. (1997). A novel transurethral microwave thermal ablation system to treat benign prostatic hyperplasia: Results of a prospective multicenter clinical trial. Journal of Urology, 158(1), 112–119. Reilly, N. J. (1997). Benign prostatic hyperplasia in older men. Lippincott’s Primary Care Practice, 1(4), 421–430. Roper, W. G. (1998). The etiology of benign prostatic hypertrophy. Medical Hypotheses, 50(1), 61–65. Wilt, T. J., Ishani, A., Stark, G., et al. (1998), Saw palmetto extracts for treatment of benign prostatic hyperplasia: A systematic review. Journal of the American Medical Association, 280(18), 1604–1609. Prostate Cancer *Agho, A. O., & Lewis, M. A. (2001). Correlates of actual and perceived knowledge of prostate cancer among African Americans. Cancer Nursing, 24(3), 165–171. Barry, M. J. (2001). Clinical practice. Prostate-specific-antigen testing for early diagnosis of prostate cancer. New England Journal of Medicine, 344(18), 1373–1377. Bickert, D., & Frickel, D. (2002). Laparoscopic radical prostatectomy. AORN Journal, 75(4), 762–780.
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Assessment and Management of Problems Related to Male Reproductive Processes
Bishoff, J. T., Motley, G., Optenberg, S. A., et al. (1998). Incidence of fecal and urinary incontinence following radical perineal and retropubic prostatectomy in a national population. Journal of Urology, 160, 454–458. Brawer, M. K., Cheli, C. D., Neaman, I. E., et al. (2000). Complexed prostate specific antigen provides significant enhancement of specificity compared with total prostate specific antigen for detecting prostate cancer. Journal of Urology, 163(5), 1476–1480. Bruner, D. W., Pickett, M., Joseph, A., & Burgraff, V. (2000). Prostate cancer elder alert (Part I): Epidemiology, screening, and early detection. Journal of Gerontological Nursing, 26(1), 6–15 Cash, J. C., & Dattoli, M. J. (1997). Management of patients receiving transperineal palladium-103 prostate implants. Oncology Nursing Forum, 24(8), 1361–1367. Cherney, N. I. (2000). The management of cancer pain. CA Cancer Journal for Clinicians, 50, 70–116. *Collins, M. (1997). Increasing prostate cancer awareness in African American men. Oncology Nursing Forum, 24(1), 91–95. D’Amico, A. V., Schultz, D., Loffredo, M., et al. (2000). Biochemical outcome following external beam radiation therapy with or without androgen suppression therapy for clinically localized prostate cancer. Journal of the American Medical Association, 284(10), 1280–1283. Denis, L. J., & Griffiths, K. (2000). Endocrine treatment in prostate cancer. Seminars in Surgical Oncology, 18, 52–74. *Esper, P., Hampton, J. N., Smith, D. C., et al. (1999). Quality-of-life evaluation in patients receiving treatment for advanced prostate cancer. Oncology Nursing Forum, 26(1), 107–112. *Fitch, M. I., Gray, R. E., Franssen, E., et al. (2000). Men’s perspectives on the impact on prostate cancer: Implications for oncology nurses. Oncology Nursing Forum, 27(8), 1255–1263. *Gelfand, D. E., Panzuchowski, S., Cort, M., et al. (1995). Digital rectal examinations and prostate cancer screening: Attitudes of African American men. Oncology Nursing Forum, 22(8), 1253–1263. Gerard, M. J., & Frank-Stromborg, M. (1998). Screening for prostate cancer in asymptomatic men: Clinical, legal, and ethical implications. Oncology Nursing Forum, 25(9), 1561–1569. Greenlee, R. T., Murray, T., Bolden, S., et al. (2001). Cancer statistics 2001. CA: A Cancer Journal for Clinicians, 51(1), 15–36. Hahnfeld, L. E., & Moon, T. D. (1999). Prostate cancer. Medical Clinics of North America, 83(5), 1231. Herr, H. W., & O’Sullivan M. (2000). Quality of life for men with prostate cancer on androgen deprivation therapy. Journal of Urology, 163, 1743–1746. Horwitz, E. M., & Hanks, G. E. (2000). External beam radiation therapy for prostate cancer. CA: Cancer Journal for Clinicians, 50(6), 349–375. *Jakobsson, L., Loven, L., & Hallberg, I. R. (2001). Sexual problems in men with prostate cancer in comparison with men with benign prostatic hyperplasia and men from the general population. Journal of Clinical Nursing, 10(4), 573–582. Kalish, L. A., & McKinlay, J. B. (1999). Serum prostate-specific antigen levels (PSA) in men without clinical evidence of prostate cancer: Agespecific reference ranges for total PSA, free PSA, and percent free PSA. Urology, 54(6), 1022–1027. Kestin, L. L., et al. (2000). Matched-pair analysis of conformal highdose-rate brachytherapy boost versus external-beam radiation therapy alone for locally advanced prostate cancer. Journal of Clinical Oncology, 18(15), 2869–2880. Krumholtz, J. S., Michalski, M. J., & Sundaram, C. P. (2000). Healthrelated quality of life and morbidity in patients receiving brachytherapy for clinically localized prostate cancer. Journal of Endourology, 14(4), 371–374. *Maliski, S. L. Heilemann, M. V., & McCorkle, R. (2002). From “death sentence” to “good cancer”: Couples’ transformation of a prostate cancer diagnosis. Nursing Research, 51(6), 391–397. Mettlin, C. (1997). National patterns of prostate cancer detection and treatment. The American Cancer Society National Prostate Cancer
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Detection Project. CA: A Cancer Journal for Clinicians, 47(5), 365–272. Middleton, R. G. (1996). The management of clinically localized prostate cancer: guidelines from the American Urological Association. CA: A Cancer Journal for Clinicians, 46(4), 249–253. *O’Rourke, M. E., & Germino, B. B. (1998). Prostate cancer treatment decisions: A focus group exploration. Oncology Nursing Forum, 25(1), 97–104. Partin, A. W., Kattan, M. W., Subong, E. N., et al. (1997). Combination of prostate-specific antigen, clinical stage, and Gleason score to predict pathological stage of localized prostate cancer. A multi-institutional update. Journal of the American Medical Association, 277(18), 1445–1451. Pickett, M., Bruner, D. W., Joseph, A., & Burgraff, V. (2000). Prostate cancer elder alert (Part II): Living with treatment choices and outcomes. Journal of Gerontological Nursing, 26(2), 22–34. Pollack, A., Zogars, G. K., Smith, L. G., et al. (2000). Preliminary results of a randomized radiotherapy dose-escalation study comparing 70 Gy with 78 Gy for prostate cancer. Journal of Clinical Oncology, 18, 3904–3911. Ragde, H., Grado, G. L., Nadir, B., et al. (2000). Modern prostate brachytherapy. CA: A Cancer Journal for Clinicians, 50(6), 380–393. Rassweiler, J., Sentker, L., Seemann, O., et al. (2001). Laparoscopic radical prostatectomy with the Heilbronn technique: An analysis of the first 180 cases. Journal of Urology, 166(6), 2101–2108. Smith, R. A., Cokkinides, V., von Eschenbach, A. C., et al. (2002). American Cancer Society Guidelines for the early detection of cancer. CA: Cancer Journal for Clinicians, 52(1), 8–22. Society of Surgical Oncology. (1997). Prostate cancer surgical practice guidelines. Oncology, 11(6), 907–912. Tarman, G. J., Kane, C. J., Moul, J. W., et al. (2000). Impact of socioeconomic status and race on clinical parameters of patients undergoing radical prostatectomy in an equal access healthcare system. Urology, 56, 1016–1020. von Eschenbach, A., Ho, R., Murphy, G. P., et al. (1997). American Cancer Society guidelines for the early detection of prostate cancer: Update 1997. CA: A Cancer Journal for Clinicians, 47(5), 261–264. *Weinrich, S. P., Weinrich, M. C., Boyd, M. D., et al. (1998). The impact of prostate cancer knowledge on cancer screening. Oncology Nursing Forum, 25(3), 527–534. *Weinrich, S. P., Reynolds, W. A., Jr., Tingen, M. S., & Starr, C. R. (2000). Barriers to prostate cancer screening. Cancer Nursing, 23(2), 117–121. *Yarbro, C. H., & Ferrans, C. E. (1998). Quality of life of patients with prostate cancer treated with surgery or radiation therapy. Oncology Nursing Forum, 25(4), 685–693. Zagaja, G. P., Mhoon, D. A., Aikens, J. E., et al. (2000). Sildenafil in the treatment of erectile dysfunction after radical prostatectomy. Urology, 56(4), 631–634. Zelefsky, M. J. (1999). Efficacy of oral sildenafil in patients with erectile dysfunction after radiotherapy for carcinoma of the prostate. Urology, 53(4), 775–778. *Zimmerman, S. M. (1997). Factors influencing Hispanic participation in prostate cancer screening. Oncology Nursing Forum, 24(3), 499–504. Testicular Cancer Agarwa, A. (2000). Semen banking in patients with cancer: 20-year experience. International Journal of Andrology, 23, Suppl 2, 16–19. American Cancer Society (2000). American Cancer Society web site (http://www.americancancer.org); accessed Aug. 12, 2002. Cox, B., Sneyd, M. J., Paul, C., et al. (2002). Vasectomy and risk of prostate cancer. Journal of the American Medical Association, 287(23), 3110–3115. Kollmannsberber, C., Kuzcyk, M., Mayer, F., et al. (1999). Late toxicity following curative treatment of testicular cancer. Seminars in Surgical Oncology, 17(4), 275–281. National Cancer Institute web site (http://cis.nci.nih.gov/asp/ FactSheetPub/FactSheetList.asp) Accessed Aug. 12, 2002.
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*Sandén, I., Larsson, U. S., & Ericksson, C. (2000). An interview study of men discovering testicular cancer. Cancer Nursing, 23(4), 304–309. Zapzalka, D. M., Redmon, J. B., & Pryor, J. L. (1999). A survey of oncologists regarding sperm cryopreservation and assisted reproductive techniques for male cancer. Cancer, 86(9), 1812–1817.
RESOURCES AND WEBSITES Agencies American Cancer Society, 1599 Clifton Road, NE, Atlanta, GA 30326; (800) ACS-2345; Man to Man Support Group; http://www. cancer.org. American Foundation for Urologic Disease, Prostate Cancer Support Network, 300 West Pratt, Suite 401, Baltimore, MD 21201-2463; (800) 828-7866; http://www.afud.org. CancerCare: 275 7th Ave., New York, NY 10001; (800) 813 HOPE (4673); http://www.cancercareinc.org/campaigns/prostate1.htm. Impotence Anonymous and I-Anon, Impotence World Association, P.O. Box 410, Bowie, MD 20718-0410; (800) 669-1603; http://www. impotenceworld.org. National Cancer Institute, Office of Cancer Communications, Building 31, Room 10A24, Bethesda, MD 20892; (800) 4-CANCER; http://www.nci.nih.gov. National Prostate Cancer Coalition, 1158 Fifteenth St. NW, Washington, D.C. 20005; (888) 245-9455; http://www.4npcc.org. Prostate Cancer At-A-Glance-Centers for Disease Control: http://www. cdc.gov/cancer/prostate/. The Prostate Cancer InfoLink: http://www.comed.com/prostate.
US Too International, Inc., Prostate Cancer Survivor Support Group, 930 North York Road, Suite 50, Hinsdale, IL 60521-2993; (800) 80-US-TOO; http://www.ustoo.com.
Patient Resources Alterowitz, R., & Alterowitz, B. (1999). The lovin’ ain’t over: The couple’s guide to better sex after prostate disease. Westbury, NY: Health Education Literary Publisher. Bostwick, D. G., MacLennan, G. T., & Larson, T. R. (eds.) (1999). The American Cancer Society: Prostate cCancer (revised ed.). New York: Villard Books. Bostwick, D. G., MacLennan, G. T., & Larson, T. R. (1999). Prostate cancer: What every man and his family needs to know. Atlanta: American Cancer Society. Marks, S. (1999). Prostate and cancer: A family guide to diagnosis, treatment and survival. Tucson, AZ: Fisher Books. National Cancer Institute (1998). Understanding prostate changes: a health guide for all men. Bethesda, MD: National Cancer Institute (NIH Pub no. 98-4303). Oesterling, J. E., & Moyad, M. A. (1997). The ABC’s of prostate cancer. Lanham: Madison Books, Inc. Rous, S. (2002). The prostate book (2nd ed.). New York: W. W. Norton. Schultz, R. E., & Oliver, A. W. (2000). Humanizing prostate cancer: A physician-patient perspective. White Stone, VA: Brandylane Publishers, Inc. Wainrib, B. R., Haber, S., & Maguire, J. (2000). Men, women and prostate cancer (2d ed.). Oakland, CA: New Harbinger Publications. Walsh, P. C., & Worthington, J. F. (1997). The prostate: A guide for men and the women who love them. New York: Warner Books. Walsh, P. C., & Worthington, J. F. (2002). Dr. Patrick Walsh’s guide to surviving prostate cancer. New York: Warner Books.
Chapter
50 ●
Assessment of Immune Function
LEARNING OBJECTIVES
●
On completion of this chapter, the learner will be able to: 1. Describe the body’s general immune responses. 2. Discuss the stages of the immune response. 3. Differentiate between cellular and humoral immune responses. 4. Describe the effects of the following variables on function of the 5.
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immune system: age, gender, nutrition, psychoneuroimmunology, concurrent illness, cancer, medications, and radiation. Use assessment parameters for determining the status of immune function.
Chapter 50
T
he immune system functions as the body’s defense mechanism against invasion. The term immunity refers to the body’s specific protective response to an invading foreign agent or organism. Immune function is affected by age and by a variety of other factors, such as central nervous system function, emotional status, medications, the stress of illness, trauma, and surgery. Dysfunctions involving the immune system occur across the life span. Many are genetically based; others are acquired. The term immunopathology refers to the study of diseases resulting from dysfunctions within the immune system. Disorders of the immune system may stem from excesses or deficiencies of immunocompetent cells, alterations in the function of these cells, immunologic attack on self-antigens, or inappropriate or exaggerated responses to specific antigens (Table 50-1). To gain insight into immunopathology and the growing number of immunologic-based disorders and to assess and care for people with immunologic disorders, the nurse needs a sound knowledge base of the immune system and how it functions.
Anatomic and Physiologic Overview ANATOMY OF THE IMMUNE SYSTEM The immune system comprises cells and molecules with specialized roles in defending against infection and invasion by other organisms. Its major components include the bone marrow, the white blood cells (WBCs) produced by the bone marrow, and the lymphoid tissues. Lymphoid tissues include the thymus gland, the spleen, the lymph nodes, the tonsils and adenoids, and similar tissues in the gastrointestinal, respiratory, and reproductive systems (Fig. 50-1).
Bone Marrow The bone marrow is the production site of the WBCs involved in immunity (Fig. 50-2). Like other blood cells, lymphocytes are generated from stem cells, which are undifferentiated cells. De-
Table 50-1
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• Immune System Disorders
DISORDER
DESCRIPTION
Autoimmunity
Normal protective immune response paradoxically turns against or attacks the body, leading to tissue damage Body produces inappropriate or exaggerated responses to specific antigens Immunoglobulins are overproduced
Hypersensitivity Gammopathies Immune deficiencies Primary
Deficiency results from improper development of immune cells or tissues, usually with a genetic basis Deficiency results from some interference with an already developed immune system
Secondary
scendants of stem cells become lymphocytes, the B lymphocytes (B cells), and the T lymphocytes (T cells) (Fig. 50-3). B lymphocytes mature in the bone marrow and then enter the circulation. T lymphocytes move from the bone marrow to the thymus, where they mature into several kinds of cells capable of different functions.
Lymphoid Tissues The spleen, composed of red and white pulp, acts somewhat like a filter. The red pulp is the site where old and injured red blood cells are destroyed. The white pulp contains concentrations of lymphocytes. The lymph nodes are distributed throughout the body. They are connected by lymph channels and capillaries, which remove foreign material from the lymph before it enters the bloodstream. The lymph nodes also serve as centers for immune cell proliferation. The remaining lymphoid tissues, such as the tonsils and adenoids and other mucoid lymphatic tissues,
Glossary agglutination: clumping effect occurring when an antibody acts as a cross-link between two antigens antibody: a protein substance developed by the body in response to and interacting with a specific antigen antigen: substance that induces the production of antibodies apoptosis: programmed cell death that results from the digestion of DNA by endonucleases B cells: cells that are important in producing circulating antibodies cellular immune response: the immune system’s third line of defense, involving the attack of pathogens by T cells complement: series of enzymatic proteins in the serum that, when activated, destroy bacteria and other cells cytokines: generic term for non-antibody proteins that act as intercellular mediators, as in the generation of immune response cytotoxic T cells: lymphocytes that lyse cells infected with virus; also play a role in graft rejection
genetic engineering: emerging technology designed to enable replacement of missing or defective genes helper T cells: lymphocytes that attack foreign invaders (antigens) directly humoral immune response: the immune system’s second line of defense; often termed the antibody response immunity: the body’s specific protective response to an invading foreign agent or organism immunopathology: study of diseases resulting in dysfunctions within the immune system immunoregulation: complex system of checks and balances that regulates or controls immune responses interferons: proteins formed when cells are exposed to viral or foreign agents; capable of activating other components of the immune system lymphokines: substances released by sensitized lymphocytes when they contact specific antigens
memory cells: cells that are responsible for recognizing antigens from previous exposure and mounting an immune response natural killer cells (NK cells): lymphocytes that defend against microorganisms and malignant cells null lymphocytes: lymphocytes that destroy antigens already coated with the antibody opsonization: the coating of antigen–antibody molecules with a sticky substance to facilitate phagocytosis phagocytic cells: cells that engulf, ingest, and destroy foreign bodies or toxins phagocytic immune response: the immune system’s first line of defense, involving white blood cells that have the ability to ingest foreign particles stem cells: precursors of all blood cells; reside primarily in bone marrow suppressor T cells: lymphocytes that decrease B-cell activity to a level at which the immune system is compatible with life
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include physical and chemical barriers, the action of WBCs, and inflammatory responses. Adenoids Tonsil Thymus
Bronchus associated lymphoid tissue
Axillary lymph nodes Spleen
Intestine
Peyer’s patches
Inguinal lymph nodes
Appendix Bone marrow
FIGURE 50-1 Central and peripheral lymphoid organs and tissues. From Porth, C. M. (2002). Pathophysiology: Concepts of altered health states (6th ed.). Philadelphia: Lippincott Williams & Wilkins.
contain immune cells that defend the body’s mucosal surfaces against microorganisms.
PHYSICAL AND CHEMICAL BARRIERS Physical surface barriers include intact skin and mucous membranes, which prevent pathogens from gaining access to the body, and the cilia of the respiratory tract along with coughing and sneezing responses, which act to filter and clear pathogens from the upper respiratory tract before they can invade the body further. Chemical barriers, such as acidic gastric secretions, mucus, enzymes in tears and saliva, and substances in sebaceous and sweat secretions, act in a nonspecific way to destroy invading bacteria and fungi. Viruses are countered by other means, such as interferon. Interferon, one type of biologic response modifier, is a nonspecific viricidal protein naturally produced by the body that is capable of activating other components of the immune system. WHITE BLOOD CELL ACTION WBCs, or leukocytes, participate in both the natural and the acquired immune responses. Granular leukocytes, or granulocytes (so called because of granules in their cytoplasm), fight invasion by foreign bodies or toxins by releasing cell mediators, such as histamine, bradykinin, and prostaglandins, and engulfing the foreign bodies or toxins. Granulocytes include neutrophils, eosinophils, and basophils. Neutrophils (also called polymorphonuclear leukocytes, or PMNs, because their nuclei have multiple lobes) are the first cells to arrive at the site where inflammation occurs. Eosinophils and basophils, other types of granulocytes, increase in number during allergic reactions and stress responses. Nongranular leukocytes include monocytes or macrophages (referred to as histiocytes when they enter tissue spaces) and lymphocytes. Monocytes also function as phagocytic cells, engulfing, ingesting, and destroying greater numbers and quantities of foreign bodies or toxins than granulocytes. Lymphocytes, consisting of B cells and T cells, play major roles in humoral and cell-mediated immune responses. About 60% to 70% of lymphocytes in the blood are T cells, and about 10% to 20% are B cells (Porth, 2002).
There are two general types of immunity: natural (innate) and acquired (adaptive). Natural immunity is a nonspecific immunity present at birth. Acquired or specific immunity develops after birth. Natural immune responses to a foreign invader are very similar from one encounter to the next regardless of the number of times the invader is encountered; in contrast, acquired responses increase in intensity with repeated exposure to the invading agent (Delves & Roitt, 2000a). Although each type of immunity plays a distinct role in defending the body against harmful invaders, the various components usually act in an interdependent manner.
INFLAMMATORY RESPONSE The inflammatory response is a major function of the natural (nonspecific or innate) immune system elicited in response to tissue injury or invading organisms. Chemical mediators assist this response by minimizing blood loss, walling off the invading organism, activating phagocytes, and promoting formation of fibrous scar tissue and regeneration of injured tissue. (The inflammatory response is discussed further in Chap. 6.) Dysfunction of the natural immune system can occur when the immune components are inactivated or when they remain active long after their effects are beneficial. Immunodeficiencies are characterized by inactivation or impairment of immune components, and disorders with an inflammatory component (eg, asthma, allergy, arthritis) are characterized by persistent inflammatory responses (Medahitov & Janeway, 2000). The immune system’s recognition of one’s own tissues as “foreign” rather than as self is the basis for many autoimmune disorders.
Natural Immunity
Acquired Immunity
Natural (innate) immunity provides a nonspecific response to any foreign invader, regardless of the invader’s composition. The basis of natural defense mechanisms is the ability to distinguish between friend and foe or “self” and “nonself.” Such natural mechanisms
Acquired (adaptive) immunity—immunologic responses acquired during life but not present at birth—usually develops as a result of prior exposure to an antigen through immunization (vaccination) or by contracting a disease, both of which generate a protective
IMMUNE FUNCTION: DEFENSES AND RESPONSES
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Physiology/Pathophysiology
Bone Marrow
Lymphoblasts
Bone marrow maturation
Thymus
Regulator T cells
Effector T cells
B lymphocytes
Memory cells
Plasma cells
Helper T cells
Suppressor T cells
Cytotoxic T cells
Antibodies
Humoral response
FIGURE 50-2
Cellular (cell-mediated) response
Development of cells of the immune system.
immune response. Weeks or months after exposure to the disease or vaccine, the body produces an immune response that is sufficient to defend against the disease upon re-exposure to it. The two types of acquired immunity are known as active and passive. In active acquired immunity, the immunologic defenses are developed by the person’s own body. This immunity generally lasts many years or even a lifetime. Passive acquired immunity is temporary immunity transmitted from another source that has developed immunity through previous disease or immunization. For example, immune globulin and antiserum, obtained from the blood plasma of people with acquired immunity, are used in emergencies to provide immunity to diseases when the risk for contracting a specific disease is great and there is not enough time for a person to develop adequate active immunity. For example, immune globulin may be administered to those exposed to hepatitis. Immunity resulting from the transfer of antibodies from the mother to an infant in utero or through breastfeeding is another example of passive immunity. Active and passive acquired immunity involve humoral and cellular (cell-mediated) immunologic responses (described later in this chapter) (Ada, 2001).
Response to Invasion When the body is invaded or attacked by bacteria, viruses, or other pathogens, it has three means of defending itself:
• The phagocytic immune response • The humoral or antibody immune response • The cellular immune response The first line of defense, the phagocytic immune response, involves the WBCs (granulocytes and macrophages), which have the ability to ingest foreign particles. These cells move to the point of attack, where they engulf and destroy the invading agents. Phagocytes also remove the body’s own dying or dead cells. Cells in necrotic tissue that are dying release substances that trigger an inflammatory response. Apoptosis, or programmed cell death, is the body’s way of destroying unwanted cells such as cancer cells or cells that die a natural death. Apoptosis involves the digestion of DNA by endonucleases, resulting in the cells being targeted for phagocytosis (Delves & Roitt, 2000a). Unlike macrophages, eosinophils are only weakly phagocytic. On activation, eosinophils probably kill parasites by releasing specific chemical mediators into the extracellular fluid. Additionally, they secrete leukotrienes, prostaglandins, and various cytokines (Delves & Roitt, 2000a). A second protective response, the humoral immune response (sometimes called the antibody response), begins with the B lymphocytes, which can transform themselves into plasma cells that manufacture antibodies. These antibodies, highly specific proteins, are transported in the bloodstream and attempt to disable
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IMMUNOLOGIC FUNCTION
NURSING RESEARCH PROFILE 50-1
Bone marrow or fetal liver
Epidural Anesthesia and Immune Response in Postpartum Women
Pluripotent stem cell
Fehder, W. P., & Gennaro, S. G. (1998). Immune alterations associated with epidural anesthesia for labor and delivery. Maternal Child Health Nursing, 23(6), 292–299
Thymus
Purpose Epidural anesthesia is a common form of analgesia and anesthesia used for women in labor. Although epidural anesthesia is regarded as safe, the results of studies have suggested that epidural anesthesia may be associated with alterations in white blood cell counts. The purpose of this study was to determine if epidural anesthesia is associated with alterations in immune profile or immune function in healthy postpartum women.
Lymphocyte stem cell
T cell B cell
Lymphoid tissue (lymph nodes, spleen, blood and lymph)
FIGURE 50-3
Lymphocytes originate from stem cells in the bone marrow. B-lymphocytes mature in the bone marrow before entering the bloodstream, whereas T lymphocytes mature in the thymus, where they also differentiate into cells with various functions. From Porth, C. M. (2002). Pathophysiology: Concepts of altered health states (6th ed.). Philadelphia: Lippincott Williams & Wilkins.
the invaders. The third mechanism of defense, the cellular immune response, also involves the T lymphocytes, which can turn into special cytotoxic (or killer) T cells that can attack the pathogens themselves. The part of the invading or attacking organism that is responsible for stimulating antibody production is called an antigen (or an immunogen). For example, an antigen can be a small patch of proteins on the outer surface of the microorganism. Not all antigens are naturally immunogenic and must be coupled to other molecules to stimulate the immune response. A single bacterium, even a single large molecule, such as a toxin (diphtheria or tetanus toxin), may have several such antigens, or markers, on its surface, thus inducing the body to produce a number of different antibodies. Once produced, an antibody is released into the bloodstream and carried to the attacking organism. There it combines with the antigen, binding with it like an interlocking piece of a jigsaw puzzle (Fig. 50-4). There are four well-defined stages in an immune response: recognition, proliferation, response, and effector. RECOGNITION STAGE Recognition of antigens as foreign, or nonself, by the immune system is the initiating event in any immune response. The body
Study Sample and Design In this prospective study, the convenience sample included two groups of healthy postpartum women. They were assessed for differences in immune profile and immune function based upon whether they received epidural anesthesia during labor and delivery. Twenty-one subjects had received no epidural anesthesia. Forty-seven subjects had received epidural anesthesia for their deliveries. Sixty-eight women who agreed to participate in the study and met inclusion criteria underwent laboratory testing for immune profile and immune function studies. This was done within 24 hours after delivery. The data collected included measures that specifically assessed immune phenotypic profile, lymphocyte proliferative response, and NK lysis assays. Findings No differences were noted in immune profile or immune function in women who received epidural anesthesia in labor versus those who did not. Nursing Implications This study demonstrated that white blood cell count and other phenotypic measures of leukocytes are not affected by epidural anesthesia. It is suggested that the epidural anesthesia technique does not alter immune response in postpartum women, although studies with larger samples are warranted. Efforts to support the immune response in women who receive epidural anesthesia should be comparable to women who do not receive epidural anesthesia.
must first recognize invaders as foreign before it can react to them. The body accomplishes recognition using lymph nodes and lymphocytes for surveillance. Lymph nodes are widely distributed internally throughout the body and in the circulating blood, and externally near the body’s surfaces. They continuously discharge small lymphocytes into the bloodstream. These lymphocytes patrol the tissues and vessels that drain the areas served by that node. Lymphocytes recirculate from the blood to lymph nodes and from the lymph nodes back into the bloodstream, in a neverending series of patrols. Some circulating lymphocytes can survive for decades. Some of these small, hardy cells maintain their solitary circuits for the person’s lifetime. The exact way in which circulating lymphocytes recognize antigens on foreign surfaces is not known; however, recognition is thought to depend on specific receptor sites on the surface of the lymphocytes. Macrophages play an important role
Chapter 50 Physiology/Pathophysiology
Antibody A
Antigen Antibody B
Antigenbinding sites
Antibody C
FIGURE 50-4
Antibody specificity. Antibodies are produced by B-cell lymphocytes to bind with specific antigens.
in helping the circulating lymphocytes process the antigens. Both macrophages and neutrophils have receptors for antibodies and complement; as a result, the coating of microorganisms with antibodies, complement, or both enhances phagocytosis. The engulfed microorganisms are then subjected to a wide range of toxic intracellular molecules. When foreign materials enter the body, a circulating lymphocyte comes into physical contact with the surfaces of these materials. Upon contact, the lymphocyte, with the help of macrophages, either removes the antigen from the surface or in some way picks up an imprint of its structure, which comes into play with subsequent re-exposure to the antigen. In a streptococcal throat infection, for example, the streptococcal organism gains access to the mucous membranes of the throat. A circulating lymphocyte moving through the tissues of the neck comes in contact with the organism. The lymphocyte, familiar with the surface markers on the cells of its own body, recognizes the antigens on the microbe as different (nonself) and the streptococcal organism as antigenic (foreign). This triggers the second stage of the immune response—proliferation. PROLIFERATION STAGE The circulating lymphocyte containing the antigenic message returns to the nearest lymph node. Once in the node, the sensitized lymphocyte stimulates some of the resident dormant T and B lymphocytes to enlarge, divide, and proliferate. T lymphocytes differentiate into cytotoxic (or killer) T cells, whereas B lymphocytes produce and release antibodies. Enlargement of the lymph nodes in the neck in conjunction with a sore throat is one example of the immune response.
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RESPONSE STAGE In the response stage, the changed lymphocytes function either in a humoral or a cellular fashion. The production of antibodies by the B lymphocytes in response to a specific antigen begins the humoral response. Humoral refers to the fact that the antibodies are released into the bloodstream and so reside in the plasma (fluid fraction of the blood). With the initial cellular response, the returning sensitized lymphocytes migrate to areas of the lymph node (other than those areas containing lymphocytes programmed to become plasma cells). Here, they stimulate the residing lymphocytes to become cells that will attack microbes directly rather than through the action of antibodies. These transformed lymphocytes are known as cytotoxic (killer) T cells. The T stands for thymus, signifying that during embryologic development of the immune system, these T lymphocytes spent time in the thymus of the developing fetus, where they were genetically programmed to become T lymphocytes rather than the antibody-producing B lymphocytes. Viral rather than bacterial antigens induce a cellular response. This response is manifested by the increasing number of T lymphocytes (lymphocytosis) seen in the blood smears of people with viral illnesses, such as infectious mononucleosis. (Cellular immunity is discussed in further detail later in this chapter.) Most immune responses to antigens involve both humoral and cellular responses, although one usually predominates. For example, during transplantation rejection, the cellular response predominates, whereas in the bacterial pneumonias and sepsis, the humoral response plays the dominant protective role (Chart 50-1). EFFECTOR STAGE In the effector stage, either the antibody of the humoral response or the cytotoxic (killer) T cell of the cellular response reaches and couples with the antigen on the surface of the foreign invader. The coupling initiates a series of events that in most instances results in the total destruction of the invading microbes or the complete neutralization of the toxin. The events involve an interplay of antibodies (humoral immunity), complement, and action by the cytotoxic T cells (cellular immunity). Figure 50-5 summarizes the stages of the immune response.
Chart 50-1
Role of Cellular and Humoral Immune Responses
Whereas B-cell antibodies are distinctive components of the humoral immune response, cytotoxic T cells are distinguishing components of the cellular immune response. Some specific roles of B cells and T cells are as follows: Humoral Responses (B Cells) • Bacterial phagocytosis and lysis • Anaphylaxis • Allergic hay fever and asthma • Immune complex disease • Bacterial and some viral infections Cellular Responses (T Cells) • Transplant rejection • Delayed hypersensitivity (tuberculin reaction) • Graft-versus-host disease • Tumor surveillance or destruction • Intracellular infections • Viral, fungal, and parasitic infections
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Physiology/Pathophysiology Antigen Foreign substance Tissue
Lymphocyte Antibody
Circulating lymphocyte
Circulating lymphocytes with antigenic information proceed to nearest lymph node
Macrophage
I. Recognition Stage
Stimulation of dormant lymphocytes
Lymph node B cells
Tissue
Dormant lymphocytes
T cells
Proliferation Complement Plasma cells
Macrophage
Cytotoxic cells
Neutrophil II. Proliferation Stage Release of lymphokines
IV. Effector Stage
Antibodies released into bloodstream
Cytotoxic T cells released into bloodstream III. Response Stage
FIGURE 50-5
Stages of the immune response. (I) In the recognition stage, antigens are recognized by circulating lymphocytes and macrophages. (II) In the proliferation stage, the dormant lymphocytes proliferate and differentiate into cytotoxic (killer) T cells or B cells responsible for formation and release of antibodies. (III) In the response stage, the cytotoxic T cells and the B cells perform cellular and humoral functions, respectively. (IV) In the effector stage, antigens are destroyed or neutralized through the action of antibodies, complement, macrophages, and cytotoxic T cells.
Humoral Immune Response The humoral response is characterized by production of antibodies by the B lymphocytes in response to a specific antigen. Although the B lymphocyte is ultimately responsible for the production of antibodies, both the macrophages of natural immunity and the special T-cell lymphocytes of cellular immunity are involved in recognizing the foreign substance and in producing antibodies.
ANTIGEN RECOGNITION Several theories exist about the mechanisms by which the B lymphocytes recognize the invading antigen and respond by producing antibodies. This is probably because the B lymphocytes recognize invading antigens in more than one way and respond in several ways as well. Additionally, the B lymphocytes appear to respond to some antigens by triggering antibody formation directly. In response to other antigens, however, they need the assistance of T cells to trigger antibody formation.
Chapter 50 T cells (or T lymphocytes), part of a surveillance system dispersed throughout the body, recycle through the general circulation, tissues, and lymphatic system. With the assistance of macrophages, the T lymphocytes are believed to recognize the antigen of a foreign invader. The T lymphocyte picks up the antigenic message, or “blueprint,” of the antigen and returns to the nearest lymph node with that message. Production of B Lymphocytes. B lymphocytes stored in the lymph nodes are subdivided into thousands of clones, each responsive to a single group of antigens having almost identical characteristics. When the antigenic message is carried back to the lymph node, specific clones of the B lymphocyte are stimulated to enlarge, divide, proliferate, and differentiate into plasma cells capable of producing specific antibodies to the antigen. Other B lymphocytes differentiate into B-lymphocyte clones with a memory for the antigen. These memory cells are responsible for the more exaggerated and rapid immune response in a person who is repeatedly exposed to the same antigen. ROLE OF ANTIBODIES Antibodies are large proteins called immunoglobulins because they are found in the globulin fraction of the plasma proteins. All immunoglobulins are glycoproteins and contain a certain amount of carbohydrate. The carbohydrate concentration, which ranges from approximately 3% to 13%, is dependent upon the class of the antibody. Each antibody molecule consists of two subunits, each of which contains a light and a heavy peptide chain (Fig. 50-6). The subunits are held together by a chemical link composed of disulfide bonds. Each subunit has a portion that serves as a binding site for a specific antigen referred to as the Fab fragment. This site provides the “lock” portion that is highly specific for an antigen. An additional portion, known as the Fc fragment, allows the antibody molecule to take part in the complement system. Antibodies defend against foreign invaders in several ways, and the type of defense employed depends on the structure and composition of both the antigen and the immunoglobulin. The antibody molecule has at least two combining sites, or Fab fragments. One antibody can act as a cross-link between two antigens, causing them to bind or clump together. This clumping effect, referred to as agglutination, helps clear the body of the in-
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vading organism by facilitating phagocytosis. Some antibodies assist in removing offending organisms through opsonization. In this process, the antigen–antibody molecule is coated with a sticky substance that also facilitates phagocytosis. Antibodies also promote the release of vasoactive substances, such as histamine and slow-reacting substance, two of the chemical mediators of the inflammatory response. Antibodies do not function in isolation but rather mobilize other components of the immune system to defend against the invader. Their usual role is to focus components of the natural immune system on the invader. This includes activation of the complement system and activation of phagocytosis (Delves & Roitt, 2000a). Types of Immunoglobulins. The body can produce five different types of immunoglobulins. (Immunoglobulins are commonly designated by the abbreviation Ig.) Each of the five types, or classes, is identified by a specific letter of the alphabet (IgA, IgD, IgE, IgG, and IgM). Classification is based on the chemical structure and biologic role of the individual immunoglobulin. The following list summarizes major characteristics of the immunoglobulins: IgG (75% of Total Immunoglobulin) Appears in serum and tissues (interstitial fluid) Assumes a major role in bloodborne and tissue infections Activates the complement system Enhances phagocytosis Crosses the placenta
• • • • •
IgA (15% of Total Immunoglobulin) • Appears in body fluids (blood, saliva, tears, breast milk, and pulmonary, gastrointestinal, prostatic, and vaginal secretions) • Protects against respiratory, gastrointestinal, and genitourinary infections • Prevents absorption of antigens from food • Passes to neonate in breast milk for protection IgM (10% of Total Immunoglobulin) • Appears mostly in intravascular serum • Appears as the first immunoglobulin produced in response to bacterial and viral infections • Activates the complement system IgD (0.2% of Total Immunoglobulin) • Appears in small amounts in serum • Possibly influences B-lymphocyte differentiation, but role is unclear IgE (0.004% of Total Immunoglobulin) • Appears in serum • Takes part in allergic and some hypersensitivity reactions • Combats parasitic infections
FIGURE 50-6 An antibody molecule. The Fab fragment serves as the binding site for a specific antigen. The Fc fragment initiates classic complement activation.
ANTIGEN–ANTIBODY BINDING The portion of the antigen involved in binding with the antibody is referred to as the antigenic determinant. The binding of the Fab fragment (antibody-binding site) to the antigenic determinant can be likened to a lock-and-key situation (Fig. 50-7). The most efficient immunologic responses occur when the antibody and antigen fit exactly. Poor fit can occur with an antibody that was produced in response to a different antigen. This phenomenon is known as cross-reactivity. For example, in acute rheumatic fever, the antibody produced against Streptococcus pyogenes in the upper respiratory tract may cross-react with the patient’s heart tissue, leading to heart valve damage.
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FIGURE 50-7 Antigen–antibody binding. (Top) A highly specific antigen– antibody complex. (Middle) No match and therefore, no immune response. (Bottom) Poor fit or match with low specificity; antibody reacts to antigen with similar characteristics, producing cross-reactivity.
Cellular Immune Response Whereas the B lymphocytes are responsible for humoral immunity, the T lymphocytes (or T cells) are primarily responsible for cellular immunity. Stem cells continuously migrate from the bone marrow to the thymus gland, where they develop into T cells. T cells continue to develop in the thymus gland, despite partial degeneration of the thymus gland that occurs at puberty (Delves & Roitt, 2000a). By spending time in the thymus, these cells are programmed to become T cells rather than antibody-producing B lymphocytes. Several types of T cells exist, each with designated roles in the defense against bacteria, viruses, fungi, parasites, and malignant cells. T cells attack foreign invaders directly rather than by producing antibodies. Cellular reactions are initiated by the binding of an antigen with an antigen receptor located on the surface of a T cell. This may occur with or without the assistance of macrophages. The T cells then carry the antigenic message, or blueprint, to the lymph nodes, where the production of other T cells is stimulated. Some T cells remain in the lymph nodes and retain a memory for the antigen. Other T cells migrate from the lymph nodes into the general circulatory system and ultimately to the tissues, where they remain until they either come in contact with their respective antigens or die. ROLE OF T LYMPHOCYTES Two major categories of effector T cells are helper T cells and cytotoxic T cells. These cells participate in destroying foreign organisms. Other T cells include suppressor T cells and memory T cells. T cells interact closely with B cells, indicating that humoral and cellular immune responses are not separate, unrelated processes but rather branches of the immune response that can and do affect each other.
Helper T cells are activated upon recognition of antigens and stimulate the rest of the immune system. When activated, helper T cells secrete cytokines that attract and activate B cells, cytotoxic T cells, natural killer cells, macrophages, and other cells of the immune system. Separate subpopulations of helper T cells produce different types of cytokines and determine whether the immune response will be the production of antibodies or a cell-mediated immune response. Helper T cells produce lymphokines, one category of cytokines. These lymphokines activate other T cells (interleukin-2 [IL-2]), natural and cytotoxic T cells (interferongamma), and other inflammatory cells (tumor necrosis factor). Helper T cells produce IL-4 and IL-5, lymphokines that activate B cells to grow and differentiate (Table 50-2). Cytotoxic T cells (killer T cells) attack the antigen directly by altering the cell membrane and causing cell lysis (disintegration) and releasing cytolytic enzymes and cytokines. Lymphokines can recruit, activate, and regulate other lymphocytes and WBCs. These cells then assist in destroying the invading organism. Delayedtype hypersensitivity is an example of an immune reaction that protects the body from antigens through the production and release of lymphokines and is discussed in more detail later. Another type of cell, the suppressor T cell, has the ability to decrease B-cell production, thereby keeping the immune response at a level that is compatible with health (eg, sufficient to fight infection adequately without attacking the body’s healthy tissues). Memory cells are responsible for recognizing antigens from previous exposure and mounting an immune response (Table 50-3). ROLES OF NULL LYMPHOCYTES AND NATURAL KILLER CELLS Null lymphocytes and natural killer (NK) cells are other lymphocytes that assist in combating organisms. These are distinct from B cells and T cells and lack the usual characteristics of B cells and T cells. Null lymphocytes, a subpopulation of lymphocytes, destroy antigens already coated with antibody. These cells have special Fc receptor sites on their surfaces that allow them to couple with the Fc end of antibodies (antibody-dependent, cell-mediated cytotoxicity). Natural killer cells, another subpopulation of lymphocytes, defend against microorganisms and some types of malignant cells. NK cells are capable of directly killing invading organisms and producing cytokines. The helper T cells contribute to the differentiation of null and NK cells.
Complement System Circulating plasma proteins, which are made in the liver and activated when an antibody couples with its antigen, are known as complement. These proteins interact sequentially with one another in a cascade or “falling domino” effect. This complement cascade alters the cell membranes on which antigen and antibody complex forms, permitting fluid to enter the cell and leading eventually to cell lysis and death. In addition, activated complement molecules attract macrophages and granulocytes to areas of antigen–antibody reactions. These cells continue the body’s defense by devouring the antibody-coated microbes and by releasing bacterial agents. Complement plays an important role in the immune response. Destruction of an invading or attacking organism or toxin is not achieved merely by the binding of the antibody and antigens; it also requires activation of complement, the arrival of killer T cells, or the attraction of macrophages. Complement has three major physiologic functions: defending the body against bacterial infection,
Chapter 50
Table 50-2
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• Cytokines and Their Biologic Effects
CYTOKINE*
ACTION
Interleukin-1 Interleukin-2
Promotes differentiation of T and B cells, natural killer (NK) cells, and null cells Stimulates growth of T cells and special activated killer lymphocytes (known as lymphocyte-activated killer cells [LAK cells]) Stimulates growth of mast cells and other blood cells Stimulates growth of T and B cells, mast cells, and macrophages Stimulates antibody responses Stimulates growth and function of B cells and antibodies Stimulates growth of pre-B, CD4, and CD8, T cells and activates mature T cells Promotes chemotaxis and activation of neutrophils Stimulates growth and proliferation of T cells Inhibits interferon-gamma and mononuclear cell inflammation Promotes induction of acute-phase proteins Introduces helper T cells Inhibits mononuclear phagocyte inflammation and promotes differentiation of B cells Promotes chemotaxis CD4 T cells and eosinophils Increases vascular permeability, allowing white cells into area Interferes with viral growth, stopping the spread of viral infection Suppresses movement of macrophages, keeping macrophages in area of foreign cells Induces inflammatory response Kills certain antigenic cells Attracts macrophages into the area Stimulates more lymphocytes, recruiting additional lymphocytes into the area Causes clumping of macrophages and lymphocytes Allows macrophages to adhere to surfaces more readily Inhibits growth of certain antigenic cells Binds to an Fc receptor on macrophages, thereby permitting macrophages to bind to antigens Stimulates inflammation, wound healing, and tissue remodeling Mediates inflammation and graft rejection
Interleukin-3 Interleukin-4 Interleukin-5 Interleukin-6 Interleukin-7 Interleukin-8 Interleukin-9 Interleukin-10 Interleukin-11 Interleukin-12 Interleukin-13 Interleukin-16 Permeability factor Interferon Migration inhibitory factor Skin reactive factor Cytotoxic factor (lymphotoxin) Macrophage chemotactic factor Lymphocyte blastogenic factor Macrophage aggregation factor Macrophage activation factor Proliferation inhibitor factor Cytophilic antibody Tumor necrosis factor (alpha) Tumor necrosis factor (beta)
*Cytokines are biologically active substances released by cells to regulate growth and function of other cells within the immune system. Lymphocytes produce lymphokines, and monocytes and macrophages produce monokines. This table lists some of the cytokines that play a role in immune system functioning.
bridging natural and acquired immunity, and disposing of immune complexes and the byproducts associated with inflammation (Walport, 2001a). Complement-mediated immune responses are summarized in Table 50-4. There are several ways to activate the complement system: the classic pathway, the alternate pathway, and the lectin pathway (Delves & Roitt, 2000a). CLASSIC PATHWAY OF COMPLEMENT ACTIVATION The classic pathway (the first method discovered) is activated by antigen–antibody complexes; it begins when antibody binds to a cell surface and ends with lysis of the cell. It involves the reaction of the first of the circulating complement proteins (C1) with the receptor site of the Fc portion of an antibody molecule after formation of an antigen–antibody complex. The activation of the first complement component then activates all the other components in the following sequence: C4, C2, C3, C5, C6, C7, C8, and C9. (The components are named in the sequence in which they were discovered.) ALTERNATE AND LECTIN PATHWAYS The alternate and lectin pathways of complement activation are activated without the formation of antigen–antibody complexes. These pathways can be initiated by the release of bacterial products, such as endotoxins. When complement is activated without the formation of antigen–antibody complexes, the process bypasses the first three components (C1, C4, and C2) and begins
with C3. Whatever the method of activation, once activated, the complement destroys cells by altering or damaging the cell membrane of the antigen, by chemically attracting phagocytes to the antigen (chemotaxis), and by rendering the antigen more vulnerable to phagocytosis (opsonization). The complement system enhances the inflammatory response by releasing vasoactive substances. Complement components, prostaglandins, leukotrienes, and other inflammatory mediators all contribute to the recruitment of inflammatory cells, as do chemokines, a group of cytokines. The activated neutrophils pass through the vessel walls to accumulate at the site of infection, where they phagocytose complementcoated microbes (Delves & Roitt, 2000a). This response is usually therapeutic and can be lifesaving if the cell attacked by the complement system is a true foreign invader, such as a streptococcal or staphylococcal organism. If that cell, however, is in reality part of the person—a cell of the brain or liver, the tissue lining the blood vessels, or the cells of a transplanted organ or skin graft, for example—the result can be devastating disease and even death. The result of the immune response—the vigorous attack on any material identified as foreign, the deadliness of the struggle—is obvious in the purulent material, or pus (the remains of microbes, granulocytes, macrophages, T-cell lymphocytes, plasma proteins, complement, and antibodies), that accumulates in wound infections and abscesses. In addition, many autoimmune diseases (ie, systemic lupus erythematosus) and disorders characterized by chronic infection
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Table 50-3
IMMUNOLOGIC FUNCTION
• Lymphocytes Involved in Immune Responses
CELL TYPE
FUNCTION
B cell
Produces antibodies or immunoglobulins (IgA, IgD, IgE, IgG, IgM)
TYPE OF IMMUNE RESPONSE
Humoral
Cellular
T cell Helper T4
Attacks foreign invaders (antigens) directly Initiates and augments inflammatory response Increases activated cytotoxic T cells Increases B-cell antibody production Suppresses the immune response Remembers contact with an antigen and on subsequent exposures mounts an immune response Lyses cells infected with virus; plays a role in graft rejection
Helper T1 Helper T2 Suppressor T Memory T
Cytotoxic T (killer T)
Natural killer (NK) (granular lymphocyte)
Destroys antigens already coated with antibody Defends against microorganisms and some types of malignant cells; produces cytokines
• Complement-Mediated Immune Responses
RESPONSE
EFFECTS
Cytolysis
Lysis and destruction of cell membranes of body cells or pathogens Targeting of the antigen so that it can be easily engulfed and digested by the macrophages and other phagocytic cells Chemical attraction of neutrophils and phagocytic cells to the antigen Activation of mast cells and basophils with release of inflammatory mediators that produce smooth muscle contraction and increased vascular permeability
Iosonization Chemotaxis Anaphylaxis
Biologic response modifiers, such as the interferons, are under investigation to determine their roles in the immune system and their potential therapeutic effects in disorders characterized by disturbed immune responses. Interferons have antiviral and antitumor properties. In addition to responding to viral infection, they are produced by T lymphocytes, B lymphocytes, and macrophages in response to antigens. They are thought to modify the immune response by suppressing antibody production and cellular immunity. They also facilitate the cytolytic role of macrophages and NK cells. Interferons are undergoing extensive testing to evaluate their effectiveness in treating tumors and acquired immunodeficiency syndrome (AIDS). Some interferons are already used to treat immune-related disorders (eg, multiple sclerosis) and chronic inflammatory conditions (eg, chronic hepatitis).
GENETIC ENGINEERING
(ie, hepatitis C, bacterial endocarditis) and necrosis (myocardial infarction, stroke) are thought to be due in part to continued or chronic activation of complement, which in turn causes chronic inflammation (Walport, 2001b). The red blood cells (erythrocytes) and platelets (thrombocytes) also have a role in the immune response. Red blood cells
Table 50-4
Role of Interferons
Advances in Immunology Nonspecific
Non-T or non-B lymphocytes Null cells
and platelets have complement receptors and as a result play an important role in the clearance of immune complexes that consist of antigen, antibody, and components of the complement system (Delves & Roitt, 2000a).
Porth, C. M. (2002). Pathophysiology: Concepts of altered health states (6th ed.). Philadelphia: Lippincott Williams & Wilkins
One of the more remarkable technologies that is evolving is genetic engineering, which involves the use of recombinant DNA technology. Two facets exist with this technology. The first permits scientists to combine genes from one type of organism with genes of a second organism. This type of technology allows cells and microorganisms to manufacture proteins, monokines and lymphokines, which can alter and enhance immune system function. The second facet of recombinant DNA technology involves gene therapy. For example, if a particular gene is abnormal or missing, a recombinant gene can be inserted onto a virus particle. When the virus splices its genes, it will automatically insert the missing gene, which theoretically will correct the situation and revitalize the immune system in an immune deficiency disorder. These genes can be carried via harmless viruses, inactivated retroviruses, grafted onto a protein carrier, or hidden in fat globules that are known as liposomes (Delves & Roitt, 2000b). Extensive research into recombinant DNA technology and gene therapy is ongoing.
STEM CELLS Stem cell research also is underway. The stem cell is known as a precursor cell that continually replenishes the body’s entire supply of both red and white cells. Stem cells represent only a small portion of all types of bone marrow cells. Research conducted with mouse models has demonstrated that once the immune system has been destroyed experimentally, it can be completely restored with the implantation of just a few purified stem cells. Stem cell transplantation has been carried out in humans with certain types of immune dysfunction, such as severe combined immunodeficiency (SCID) (Parslow, Stites, Terr & Imboden, 2001). Clinical trials using stem cells are underway in patients with a variety of disorders with an autoimmune component, including systemic lupus erythematosus, rheumatoid arthritis, scleroderma, and multiple sclerosis (Davidson & Diamond, 2001).
Chapter 50
Assessment of Immune Function
IMMUNOREGULATION
Chart 50-2
A successful immune response eliminates the inciting antigen. Once the antigen that has stimulated the immune response is eliminated, the response returns to a nearly normal level. This process, known as immunoregulation, balances and counterbalances the immune response. For example, autoimmune diseases can be better controlled by suppressing areas of the immune system that are overactive and boosting those areas that are underactive. Immunoregulation research holds the promise of preventing graft rejection and aiding the body in dispersing cells that are cancerous or infected (Delves & Roitt, 2000b).
Indications of Immune Dysfunction
Assessment An assessment of immune function begins with a health history and physical examination. The history should note the patient’s age along with information about past and present conditions and events that may provide clues to the status of the patient’s immune system. Areas to be addressed include nutritional status; infections and immunizations; allergies; disorder and disease states, such as autoimmune disorders, cancer, and chronic illnesses; surgery; medications; and blood transfusions. Physical assessment includes palpation of the lymph nodes and examination of the skin, mucous membranes, and respiratory, gastrointestinal, genitourinary, cardiovascular, and neurosensory systems (Chart 50-2).
HEALTH HISTORY Age Age is an important factor to elicit from the patient as people at the extremes of the life span are more likely to develop problems related to immune system functioning than are those in their middle years (Table 50-5). Gerontological Considerations The frequency and severity of infections are increased in elderly people, possibly due to a decreased ability to respond adequately to invading organisms. Both the production and the function of T and B lymphocytes may be impaired. Responses to antigen stimulation may be altered, with increasing proportions of lymphocytes becoming unresponsive with age (Porth, 2002). The incidence of autoimmune diseases also increases with aging, possibly from a decreased ability of antibodies to differentiate between self and nonself. Failure of the surveillance system to recognize mutant, or abnormal, cells may be responsible for the high incidence of cancer associated with increasing age. Declining function of various organ systems associated with increasing age also contributes to impaired immunity. Decreased gastric secretions and motility allow normal intestinal flora to proliferate and produce infection, causing gastroenteritis and diarrhea. Decreased renal circulation, filtration, absorption, and excretion contribute to risk for urinary tract infections. Moreover, prostatic enlargement and neurogenic bladder can impede urine passage and subsequently bacterial clearance through the urinary system. Urinary stasis, common in elderly people, permits the growth of microorganisms. Exposure to tobacco and environmental toxins impairs pulmonary function. Prolonged exposure to these agents decreases the elasticity of lung tissue, the effec-
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• ASSESSMENT
Respiratory System • Changes in respiratory rate • Cough (dry or productive) • Abnormal lung sounds (wheezing, crackles, rhonchi) • Rhinitis • Hyperventilation • Bronchospasm Cardiovascular System • Hypotension • Tachycardia • Dysrhythmia • Vasculitis • Anemia Gastrointestinal System • Hepatosplenomegaly • Colitis • Vomiting • Diarrhea Genitourinary System • Frequency and burning on urination • Hematuria • Discharge Skin • Rashes • Lesions • Dermatitis • Hematomas or purpura • Edema or urticaria • Inflammation • Discharge Neurosensory System • Cognitive dysfunction • Hearing loss • Visual changes • Headaches and migraines • Ataxia • Tetany
tiveness of cilia, and the ability to cough effectively. These impairments hinder the removal of infectious organisms and toxins, increasing the elderly person’s susceptibility to pulmonary infections and cancers. Finally, with aging, the skin becomes thinner and less elastic. Peripheral neuropathy and the accompanying decreased sensation and circulation may lead to stasis ulcers, pressure ulcers, abrasions, and burns. Impaired skin integrity predisposes the aging person to infection from organisms that are part of normal skin flora.
Nutrition The nurse assesses the patient’s nutritional status, including caloric intake as well as the type of calories that the patient is consuming. Adequate nutrition is essential for optimal functioning of the immune system. Inadequate intake of vitamins that are essential for DNA and protein synthesis may lead to protein-calorie deficiency and subsequently to impaired immune function. Vitamins also
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Table 50-5
IMMUNOLOGIC FUNCTION
• Age-Related Changes in Immunologic Function
BODY SYSTEM
CHANGES
CONSEQUENCES
Immune system
Impaired function of B and T lymphocytes Failure of lymphocytes to recognize mutant or abnormal cells Decreased antibody production Failure of immune system to differentiate “self” from “non-self” Suppressed phagocytic immune response
Gastrointestinal system
Decreased gastric secretions and motility Decreased phagocytosis by the liver’s Kupffer cells Altered nutritional intake with inadequate protein intake
Urinary system
Decreased kidney function and changes in lower urinary tract function (enlargement of prostate gland, neurogenic bladder). Altered genitourinary tract flora. Impaired ciliary action due to exposure to smoke and environmental toxins Thinning of skin with less elasticity; loss of adipose tissue Impaired microcirculation Decreased sensation and slowing of reflexes
Suppressed responses to pathogenic organisms with increased risk for infection Increased incidence of cancers Anergy (lack of response to antigens applied to the skin [PPD, allergens]) Increased incidence of autoimmune diseases Absence of typical signs and symptoms of infection and inflammation Dissemination of organisms usually destroyed or suppressed by phagocytes (reactivation or spread of TB) Proliferation of intestinal organisms resulting in gastroenteritis and diarrhea Increased incidence and severity of hepatitis B; increased incidence of liver abscesses Suppressed immune response Urinary stasis and increased incidence of urinary tract infections
Pulmonary system Integumentary system Circulatory system Neurologic function
help in the regulation of cell proliferation and maturation of immune cells. Excess or deficiency of trace elements (ie, copper, iron, manganese, selenium, or zinc) in the diet generally suppresses immune function. Fatty acids are the building blocks that make up the structural components of cell membranes. Lipids are precursors of vitamins A, D, E, and K as well as cholesterol. Both excess and deficiency of fatty acids have been found to suppress immune function. Depletion of protein reserves results in atrophy of lymphoid tissues, depression of antibody response, reduction in the number of circulating T cells, and impaired phagocytic function. As a result, susceptibility to infection is greatly increased. During periods of infection and serious illness, nutritional requirements may be exaggerated further, potentially contributing to depletion of protein, fatty acid, vitamin, and trace elements and an even greater risk of impaired immune response and sepsis.
Infection and Immunization The patient is asked about immunizations (including those received recently and those received in childhood) and the usual childhood diseases. Known past or present exposure to tuberculosis is assessed, and the dates and results of any tuberculin tests (purified protein derivative [PPD] or tine test) and chest x-rays are obtained. Recent patient exposure to any infections and the exposure dates are elicited. It is important for the nurse to assess whether the patient has been exposed to any sexually transmitted diseases and bloodborne pathogens such as hepatitis A, B, C, D, and E infections, and HIV infection. A history of sexually transmitted diseases, such as gonorrhea, syphilis, HPV infection, and chlamydia, can alert the nurse that the patient may have been exposed to HIV infection or hepatitis. A history of past and present
Impaired clearance of pulmonary secretions; increased incidence of respiratory infections Increased risk of skin injury, breakdown and infection Stasis and pressure ulcers Increased risk of injury (ulcers, abrasions, burns)
infections and the dates and types of treatments that were used, along with a history of any multiple persistent infections, fevers of unknown origin, lesions or sores, or any type of drainage, are obtained.
Allergy The patient is asked about history of any allergies, including types of allergens (pollens, dust, plants, cosmetics, food, medications, vaccines), the symptoms experienced, and seasonal variations in occurrence or severity in the symptoms. A history of testing and treatments that the patient has received or is currently receiving for these allergies and the effectiveness of the treatments is obtained. All medication and food allergies are listed on an allergy alert sticker and placed on the front of the patient’s health record or chart to alert others to the possibility of these allergies. Continued assessment for potential allergic reactions in this patient is vital.
Disorders and Diseases AUTOIMMUNE DISORDERS The patient is asked about any autoimmune disorders, such as lupus erythematosus, rheumatoid arthritis, or psoriasis. The onset, severity, remissions and exacerbations, functional limitations, treatments that the patient has received or is currently receiving, and the effectiveness of the treatments are described. Although most autoimmune disorders are individually rare, together they affect approximately 5% of the U.S. population. The occurrence of different autoimmune diseases within a family strongly suggests a genetic predisposition to more than one autoimmune disease (Davidson & Diamond, 2001).
Chapter 50 In general, autoimmune disorders are more common in females than in males. This is believed to be the result of the activity of the sex hormones. The ability of sex hormones to modulate immunity has been well established. There is evidence that estrogen modulates the activity of T lymphocytes (especially suppressor cells), whereas androgens act to preserve IL-2 production and suppressor cell activity. The effects of sex hormones on B cells are less pronounced. Estrogen activates the autoimmune-associated B-cell population that expresses the CD5 marker (an antigenic marker on the B cell). Estrogen tends to enhance immunity, whereas androgen tends to be immunosuppressive. NEOPLASTIC DISEASE A history of cancer in the patient is obtained, along with the type of cancer and date of diagnosis. Dates and results of any cancer screening tests are also obtained. Immunosuppression contributes to the development of cancers; however, cancer itself is immunosuppressive. Large tumors can release antigens into the blood, and these antigens combine
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with circulating antibodies and prevent them from attacking the tumor cells. Furthermore, tumor cells may possess special blocking factors that coat tumor cells and prevent destruction by killer T lymphocytes. During the early development of tumors, the body may fail to recognize the tumor antigens as foreign and subsequently fail to initiate destruction of the malignant cells. Hematologic cancers, such as leukemia and lymphoma, are associated with altered production and function of WBCs and lymphocytes. All treatments that the patient has received or is currently receiving, such as radiation or chemotherapy, are identified and documented in the health history. Radiation destroys lymphocytes and decreases the population of cells required to replace them. The size or extent of the irradiated area determines the extent of immunosuppression. Whole-body irradiation may leave the patient totally immunosuppressed. Chemotherapy also destroys immune cells and causes immunosuppression. A family history of cancer is obtained. If there is a family history of cancer, the type of cancer, age of onset, and relationship (maternal or paternal) of the patient to the affected family member is noted. (See Genetics in Nursing Practice.)
GENETICS IN NURSING PRACTICE—Immunologic Disorders IMMUNOLOGIC DISORDERS INFLUENCED BY GENETIC FACTORS • Ankylosing spondylitis • Ataxia-telangiectasia • Bloom syndrome • Common variable immunodeficiency • Fanconi anemia • Rheumatoid arthritis • Systemic lupus erythematosus (SLE) • Severe combined immune deficiency (SCID) NURSING ASSESSMENTS FAMILY HISTORY ASSESSMENT
• Inquire about rheumatic diseases such as rheumatoid arthri• • •
tis, ankylosing spondylitis, and systemic lupus erythematosus in other family members in several generations. Inquire about ethnic background (eg, Bloom syndrome is common among individuals of Ashkenazi heritage). Assess family history for closely related members with immune deficiency. Determine the age of onset of symptoms in affected family members (eg, for SCID, symptoms of pneumonia and unresponsive candidiasis are evident within the first 3 months of life).
PHYSICAL ASSESSMENT
• In children, assess for other clinical signs of immune dysfunc• •
tion, including failure to thrive, growth retardation, developmental delays, pallor, irritability. Assess skin for cutaneous telangiectases (spider-like blood vessels in ataxia telangiectasia, or as in Bloom syndrome in a butterfly pattern on the nose and cheeks). Assess for hyperpigmentation, short stature, and other organ involvement seen in Fanconi anemia.
MANAGEMENT ISSUES SPECIFIC TO GENETICS • Inquire whether DNA mutation or other genetic testing has been performed on affected family members. • If indicated, refer for further genetic counseling and evaluation so that family members can discuss inheritance, risk to other family members, availability of genetic testing and gene-based interventions. • Offer appropriate genetics information and resources. • Assess patient’s understanding of genetics information. • Provide support to families with newly diagnosed geneticrelated immune disorders. • Participate in management and coordination of care of patients with genetic conditions and individuals predisposed to develop or pass on a genetic condition. GENETIC RESOURCES FOR NURSES AND THEIR PATIENTS ON THE WEB Genetic Alliance http://www.geneticalliance.org—a directory of support groups for patients and families with genetic conditions Gene Clinics http://www.geneclinics.org—a listing of common genetic disorders with clinical summaries, genetic counseling and testing information Immune Deficiency Foundation http://www.primaryimmune. org—offers general information, peer support, and other resources for families with immune disorders National Organization of Rare Disorders http://www. rarediseases.org—a directory of support groups and information for patients and families with rare genetic disorders OMIM: Online Mendelian Inheritance in Man http://www. ncbi.nlm.nih.gov/omim/stats/html—a complete listing of inherited genetic conditions
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CHRONIC ILLNESS AND SURGERY The health assessment includes a history of chronic illnesses, such as diabetes mellitus, renal disease, or chronic obstructive pulmonary disease. The onset and severity of illnesses, as well as treatment that the patient is receiving for the illness, are obtained. Chronic illness may contribute to immune system impairments in various ways. Renal failure is associated with a deficiency in circulating lymphocytes. In addition, immune defenses may be altered by acidosis and uremic toxins. In diabetes, an increased incidence of infection has been associated with vascular insufficiency, neuropathy, and poor control of serum glucose levels. Recurrent respiratory tract infections are associated with chronic obstructive pulmonary disease as a result of altered inspiratory and expiratory function and ineffective airway clearance. Additionally, a history of surgical removal of the spleen, lymph nodes, or thymus or a history of organ transplantation is noted because these conditions may place the patient at risk for impaired immune function. SPECIAL PROBLEMS Conditions such as burns and other forms of injury and infection may contribute to altered immune system function. Major burns or other factors cause impaired skin integrity and compromise the body’s first line of defense. Loss of large amounts of serum with burn injuries depletes the body of essential proteins, including immunoglobulins. The physiologic and psychological stressors associated with surgery or injury stimulate cortisol release from the adrenal cortex; increased serum cortisol also contributes to suppression of normal immune responses.
Medications and Blood Transfusions A list of past and present medications is obtained. In large doses, antibiotics, corticosteroids, cytotoxic agents, salicylates, nonsteroidal anti-inflammatory drugs (NSAIDs), and anesthetics can cause immune suppression (Table 50-6). A history of blood transfusions is obtained because previous exposure to foreign antigens through transfusion may be associated with abnormal immune function. Additionally, although the risk of human immunodeficiency virus (HIV) transmission through blood transfusion is extremely low in patients who received a transfusion after 1985 (the year that testing of blood for HIV was initiated in the United States), a risk still exists. The patient is also asked about use of herbal agents and overthe-counter medications. Because many of these products have not been subjected to rigorous testing, not all of their effects have been identified. It is important, therefore, to ask patients about their use of these substances and to document their use.
Lifestyle and Other Factors Like any other body system, the immune system functions depend on other body systems. A detailed history of smoking, alcohol consumption, dietary intake and nutritional status, amount of perceived stress, injection drug use, sexual practices, sexually transmitted diseases, and occupational or residential exposure to radiation or pollutants is obtained. Poor nutritional status, smoking, excessive consumption of alcohol, injection drug use, sexually transmitted diseases, and exposure to environmental radiation and pollutants have been associated with impaired immune function and are assessed in the patient history.
Table 50-6
• Selected Medications and Effects on the Immune System
DRUG CLASSIFICATION (AND EXAMPLES)
EFFECTS ON THE IMMUNE SYSTEM
Antibiotics (in large doses) ceftriaxone (Rocefin)
Bone Marrow Suppression Eosinophilia, hemolytic anemia, hypoprothrombinemia, neutropenia, thrombocytopenia Eosinophilia, hemolytic anemia, hypoprothrombinemia, neutropenia, thrombocytopenia Leukopenia, aplastic anemia Agranulocytosis, neutropenia Hemolytic anemia, methemoglobinemia, eosinophilia, leukopenia, pancytopenia Agranulocytosis, granulocytosis Neutropenia, leukopenia
cefuroxime sodium (Ceftin)
chloramphenicol (Chloromycetin) dactinomycin (Cosmogen) fluoroquinolones (Cipro, Levaquin, Tequin) gentamicin sulfate (Garamycin) macriolides (erythromycin, Zithromax, Biaxin) penicillins streptomycin vancomycin (Vancocin, Vancoled) Antithyroid Drugs propylthiouracil (PTU) Nonsteroidal Anti-inflammatory Drugs (NSAIDs) (in large doses) aspirin cox-2 inhibitors (Vioxx, Celebrex, Bextra) ibuprofen (Advil, Motrin) indomethacin (Indocid, Indocin) phenylbutazone Adrenal Corticosteroids prednisone Antineoplastic Agents (Cytotoxic Agents) alkylating agents cyclophosphamide (Cytoxan) mechlorethamine HCl (Mustargen) cyclosporine Antimetabolites fluorouracil (pyrimidine antagonist) methotrexate (folic acid antagonist) mercaptopurine (6-MP) (purine antagonist)
Agranulocytosis Leukopenia, neutropenia, pancytopenia Transient leukopenia Agranulocytosis, leukopenia Inhibit Prostaglandin Synthesis or Release Agranulocytosis Anemia, allergy, no major other adverse affects to the immune system Leukopenia, neutropenia Agranulocytosis, leukopenia Pancytopenia, agranulocytosis, aplastic anemia Immunosuppression Immunosuppression Leukopenia Leukopenia, neutropenia Agranulocytosis, neutropenia Leukopenia, inhibits T-cell function Immunosuppression Leukopenia, eosinophilia Leukopenia, aplastic bone marrow Leukopenia, pancytopenia
PSYCHONEUROIMMUNOLOGIC FACTORS The assessment also addresses psychoneuroimmunologic factors. It is thought that the immune response is regulated and modulated in part by neuroendocrine influences. Lymphocytes and macrophages have receptors capable of responding to neurotransmitters and endocrine hormones. Lymphocytes can produce and secrete adrenocorticotropic hormone and endorphin-like
Chapter 50 compounds. Neurons in the brain, especially in the hypothalamus, can recognize prostaglandins, interferons, and interleukins as well as histamine and serotonin, which are released during the inflammatory process. Like all other biologic systems functioning in the interest of homeostasis, the immune system is integrated with other psychophysiologic processes and is subject to regulation and modulation by the brain. Conversely, the immune processes can affect neural and endocrine function, including behavior. Thus, the interaction of the nervous system and immune system appears to be bidirectional. Growing evidence indicates that measurable immune system parameters can be influenced by biobehavioral strategies involving selfregulation. Examples of these strategies are relaxation and imagery techniques, biofeedback, humor, hypnosis, and conditioning. The assessment should address the patient’s general psychological status and the patient’s use of these strategies.
PHYSICAL EXAMINATION On physical examination (see Chart 50-2), the skin and mucous membranes are assessed for lesions, dermatitis, purpura (subcutaneous bleeding), urticaria, inflammation, or any discharge. Any signs of infection are noted. The patient’s temperature is recorded, and the patient is observed for chills and sweating. The anterior and posterior cervical, axillary, and inguinal lymph nodes are palpated for enlargement; if palpable nodes are detected, the location, size, consistency, and reports of tenderness upon palpation are noted. Joints are assessed for tenderness and swelling and for limited range of motion. The patient’s respiratory, cardiovascular, gastrointestinal, genitourinary, and neurosensory status is evalu-
Chart 50-3
Assessment of Immune Function
ated for signs and symptoms indicative of immune dysfunction. The patient’s nutritional status, level of stress, and coping ability are also assessed, along with his or her age and any functional limitations or disabilities.
Diagnostic Evaluation A series of blood tests and skin tests and a bone marrow biopsy may be performed to evaluate the patient’s immune competence. Specific laboratory and diagnostic tests are discussed in greater detail along with specific disease processes in subsequent chapters in this unit. Laboratory and diagnostic tests used to evaluate immune competence are summarized in Chart 50-3.
Nursing Management The nurse needs to be aware that patients undergoing evaluation for possible immune system disorders experience not only physical pain and discomfort with certain types of diagnostic procedures, but many psychological reactions as well. For example, patients may fear test results that demonstrate decreased immune function that makes them more prone to certain infections, cancers, and other disorders. It is the nurse’s role to counsel, educate, and support patients throughout the diagnostic process. Further, many patients may be extremely anxious about the results of diagnostic tests and the possible implications of those results for their employment, insurance, and personal relationships. This is an opportune time for the nurse to provide counseling and education should these interventions be warranted.
Selected Tests for Evaluating Immunologic Status
Various laboratory tests may be performed to assess immune system activity or dysfunction. The studies assess leukocytes and lymphocytes, humoral immunity, cellular immunity, phagocytic cell function, complement activity, hypersensitivity reactions, specific antigen– antibodies, or HIV infection. Leukocytes and Lymphocyte Tests • White blood cell count and differential • Bone marrow biopsy Humoral (Antibody-Mediated) Immunity Tests • B-cell quantification with monoclonal antibody • In vivo immunoglobulin synthesis with T-cell subsets • Specific antibody response • Total serum globulins and individual immunoglobulins (by electrophoresis, immunoelectrophoresis, single radial immunodiffusion, nephelometry, isohemagglutinin techniques) Cellular (Cell-Mediated) Immunity Tests • Total lymphocyte count • T-cell and T-cell subset quantification with monoclonal antibody • Delayed hypersensitivity skin test • Cytokine production • Lymphocyte response to mitogens, antigens, and allogenic cells • Helper and suppressor T-cell functions Phagocytic Cell Function Tests • Nitroblue tetrazolium reductase assay
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Complement Component Tests • Total serum hemolytic complement • Individual complement component titrations • Radial immunodiffusion • Electroimmunoassay • Radioimmunoassay • Immunonephelometric assay • Immunoelectrophoresis Hypersensitivity Tests • Scratch test • Patch test • Intradermal test • Radioallergosorbent test (RAST) Specific Antigen-antibody Tests • Radioimmunoassay • Immunofluorescence • Agglutination • Complement fixation test HIV Infection Tests • Enzyme-linked immunosorbent assay (ELISA) • Western blot • CD4 and CD8 cell counts • P24 antigen test • Polymerase chain reaction (PCR)
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Critical Thinking Exercises
1.
An 18-year-old man presents for a physical examination to enter college. His mother asks if her son should receive a vaccination to prevent meningococcal meningitis. How would you respond? What recommendations would you give her, and why?
2. A 68-year-old woman is hospitalized for a heart transplant, and immune suppressant medications are given. Describe the parameters you would use to assess her immune function. How would altered immune function affect the care that you provide?
3.
An 84-year-old woman who lives alone and has a long history of use of corticosteroids to treat rheumatoid arthritis is hospitalized with pneumonia. Discuss the changes in her immune status due to aging that need to be considered in her care. Identify the assessment strategies that are indicated.
REFERENCES AND SELECTED READINGS Books Abbas, A. K., & Lichtman, A. H. (2001). Basic immunology: Functions and disorders of the immune system. Philadelphia: W. B. Saunders Co. Buttaro, T. M., Trybulski, J., Bailey, P. P., & Sandberg-Cook, J. (1999). Primary care: A collaborative practice. St. Louis, MO: Mosby, Inc. Eisenhauer, L., Nichols, L. W., Spencer, R. T., & Bergan, F. W. (1998). Clinical pharmacology and nursing management (5th ed.). Philadelphia: Lippincott-Raven. Goroll, A. H., & Mulley, A. G. Jr. (2000). Primary care medicine (4th ed.). Philadelphia: Lippincott Williams & Wilkins. Huether, S. E., & McCance, K. L. (2000). Understanding pathophysiology (2d ed.). St. Louis, MO: Mosby, Inc. Molony, S. L., Waszynski, C. M., & Lyder, C. H. (1999). Gerontological nursing: An advanced practice approach. Stamford, CT: Appleton & Lange. Parkinson, C. F. (2000). Study guide and workbook for understanding pathophysiology (2d ed.). St. Louis, MO: Mosby, Inc.
Parslow, T. G., Stites, D. P., Terr, A. K., & Imboden, J. B. (2001). Medical immunology (10th ed.). New York: McGraw-Hill. Porth, C. M., (2002). Pathophysiology: Concepts of altered health states. Philadelphia: Lippincott Williams & Wilkins. Rich, R. (Ed.) (2001). Clinical immunology: Principles and practice (Vol. II). Philadelphia: Mosby. Roitt, I., & Delves, P. J. (2001). Roitt’s essential immunology. Malden, MA: Blackwell Science.
Journals Asterisks indicate nursing research articles. Ada, G. (2001). Vaccines and vaccination. New England Journal of Medicine, 345(14), 1042–1053. Davidson, A., & Diamond, B. (2001). Advances in immunology: Autoimmune diseases. New England Journal of Medicine, 345(5), 340–350. Delves, P. J., & Roitt, I. M. (2000a). Advances in immunology: The immune system (first of two parts). New England Journal of Medicine, 343(1), 37–49. Delves, P. J., & Roitt, I. M. (2000b). Advances in immunology: The immune system (second of two parts). New England Journal of Medicine, 343(2), 108–117. Fehder, W. P., & Douglas, S. D. (2001). Interactions between the nervous and immune systems. Seminars in Clinical Neuropsychiatry, 6(4), 229–240. *Fehder, W. P., & Gennaro, S. (1998). Immune alterations associated with epidural analgesia for labor and delivery. Maternal Child Health Nursing, 23(6), 292–299. Luster, A. D. (1998). Chemokines—chemotactic cytokines that mediate inflammation. New England Journal of Medicine, 338(7), 436–445. Medahitov, R., & Janeway C. Jr. (2000). Innate immunity. New England Journal of Medicine, 343(5), 338–344. Walport, M. J. (2001a). Advances in immunology: Complement (first of two parts). New England Journal of Medicine, 344(14), 1058–1066. Walport, M. J. (2001b). Advances in immunology: Complement (second of two parts). New England Journal of Medicine, 344(14), 1140–1144.
RESOURCES AND WEBSITES Centers for Disease Control and Prevention, 1600 Clifton Road, Atlanta, GA 30333; (404) 639-3311, (800) 311-3435; http://www.cdc.gov. National Institute of Allergy and Infectious Disease, Office of Communication and Public Liaison, Building 31, Room 7A-50, 31 Center Drive MSC 2520, Bethesda, MD, 20892-2520; http://www.niaid.nih.gov/. National Institutes of Health, Bethesda, Maryland; http://nih.gov. For toll-free information line for NIH departments: http://www.nih.gov/ health/infoline.htm.
Chapter
51 ●
Management of Patients With Immunodeficiency
LEARNING OBJECTIVES
●
On completion of this chapter, the learner will be able to: 1. Compare the different types of primary immunodeficiency disor2. 3. 4.
ders, addressing causes, clinical manifestations, management, possible complications, and available treatments. Discuss the possible management of patients with immunodeficiency disorders. Describe the nursing management of the patient with an immunodeficiency. Identify the teaching points necessary for a patient with an immunodeficiency.
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mmunodeficiency disorders may be caused by a defect or deficiency in phagocytic cells, B lymphocytes, T lymphocytes, or the complement system. The specific symptoms and their severity, age of onset, and prognosis depend on the immune system components affected and their degree of functional impairment. Regardless of the underlying cause, the cardinal symptoms of immunodeficiency include chronic or recurrent severe infections, infections caused by unusual organisms or organisms that are normal body flora, poor response to treatment of infections, and chronic diarrhea. In addition, the patient is susceptible to a variety of secondary disorders, including cancer (Buckley, 2000). Immunodeficiencies may be classified as either primary or secondary and by the components of the immune system that are affected. Primary immunodeficiency diseases are genetic in origin and are caused by intrinsic defects in the cells of the immune system. This is in contrast to secondary immunodeficiencies such as AIDS, caused by infection with human immunodeficiency virus (HIV). Knowledge of the immune system and of the possibility of secondary disorders, skillful assessment and management, and sensitivity and responsiveness to the learning needs of the patient and caregiver are the essential elements for effective nursing care.
Primary Immunodeficiencies Primary immunodeficiencies, rare disorders with genetic origins, are seen primarily in infants and young children. To date, more than 95 immunodeficiencies of genetic origin have been identified (Buckley, 2000). Symptoms usually develop early in life after protection from maternal antibodies decreases. Without treatment, infants and children with these disorders seldom survive to adulthood. These disorders may involve one or more components of the immune system. Symptoms of immune deficiency diseases are related to the role that the deficient component normally plays (Table 51-1).
PHAGOCYTIC DYSFUNCTION
Clinical Manifestations Phagocytic cell disorders are manifested by an increased incidence of bacterial and fungal infections due to normally nonpathogenic organisms (Lekstrom-Himes & Gallin, 2002). People with these disorders may also develop fungal infections from Candida organisms and viral infections from herpes simplex or herpes zoster virus. These patients experience recurrent furunculosis, cutaneous abscesses, chronic eczema, bronchitis, pneumonia, chronic otitis media, and sinusitis. In one type of phagocytic disorder, hyperimmunoglobulinemia E (HIE) syndrome, formerly known as Job syndrome, white blood cells cannot produce an inflammatory response to the skin infections; this results in deep-seated cold abscesses that lack the classic signs and symptoms of inflammation (redness, heat, and pain). While patients with phagocytic cell disorders may be asymptomatic, severe neutropenia may be accompanied by deep and painful mouth ulcers, gingivitis, stomatitis, and cellulitis. Death from overwhelming infection occurs in about 10% of patients with severe neutropenia. Chronic granulomatous disease, another type of primary phagocytic disorder, produces recurrent or persistent infections of the soft tissues, lungs, and other organs; these are resistant to aggressive treatment with antibiotics (Lekstrom-Himes & Gallin, 2002).
Assessment and Diagnostic Findings Diagnosis is based on the history, signs and symptoms, and laboratory analysis of the cytocidal (causing the death of cells) activity of the phagocytic cells by the nitroblue tetrazolium reductase test (see Chart 50-3 in Chap. 50). A history of recurrent infection and fever in a child and occasionally in an adult is an important key to the diagnosis. Failure of an infection to resolve with usual treatment is also an important indicator (Lekstrom-Himes & Gallin, 2002). See Chart 51-1 for a summary of warning signs of primary immunodeficiency disorders.
Medical Management
Pathophysiology A variety of primary defects of phagocytes may occur; nearly all of them are genetic in origin and affect the innate immune system. In some types of phagocytic disorders, the neutrophils are impaired so that they cannot exit the circulation and travel to sites of infection. As a result the patient cannot mount a normal inflammatory response against pathogenic organisms (Lekstrom-Himes & Gallin, 2002). In some disorders, the neutrophil count may be very low; in others, it may be very high because the neutrophils remain in the vascular system.
Because the signs and symptoms of infection are often blunted because of an impaired inflammatory response, early diagnosis and treatment of infectious complications can be lifesaving (Lekstrom-Himes & Gallin, 2002). Management of phagocytic cell disorders includes treating bacterial infections with prophylactic antibiotic therapy. Additional treatment for fungal and viral infections is often needed. Granulocyte transfusions, although used, are seldom successful because of the short half-life of the cells. Treatment with granulocyte-macrophage colony-stimulating factor (GM-CSF) or granulocyte colony-stimulating factor (G-CSF) may
Glossary agammaglobulinemia: disorder marked by an almost complete lack of immunoglobulins or antibodies angioneurotic edema: condition marked by development of urticaria and an edematous area of skin, mucous membranes, or viscera ataxia: uncoordinated muscle movement ataxia-telangiectasia: autosomal recessive disorder affecting T- and B-cell immunity primarily seen in children and resulting in a degenerative brain disease
hypogammaglobulinemia: lack of one or more of the five immunoglobulins; caused by B-cell deficiency immunocompromised host: person with a secondary immunodeficiency and associated immunosuppression panhypoglobulinemia: general lack of immunoglobulins in the blood severe combined immunodeficiency disease (SCID): disorder involving a complete absence of humoral and cellular
immunity resulting from an X-linked or autosomal genetic abnormality telangiectasia: vascular lesions caused by dilated blood vessels thymic hypoplasia: T-cell deficiency that occurs when the thymus gland fails to develop normally during embryogenesis; also known as DiGeorge syndrome Wiskott-Aldrich syndrome: immunodeficiency characterized by thrombocytopenia and the absence of T and B cells
Chapter 51
Table 51-1
Management of Patients With Immunodeficiency
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• Selected Primary Immunodeficiency Disorders
IMMUNE COMPONENT
DISORDER
MAJOR SYMPTOMS
TREATMENT
Phagocytic cells
Hyperimmunoglobulinemia E (HIE) syndrome
Bacterial, fungal, and viral infections; deep-seated cold abscesses
B lymphocytes
Sex-linked agammaglobulinemia (Bruton’s disease) Common variable immunodeficiency (CVID)
Severe infections soon after birth
Antibiotic therapy and treatment for viral and fungal infections Granulocyte-macrophage colonystimulating factor (GM-CSF); granulocyte colony-stimulating factor (G-CSF) Passive pooled plasma or gammaglobulin IV immunoglobulin Metronidazole (Flagyl) Quinacrine HCl (Atabrine) Vitamin B12 Antimicrobial therapy None
Immunoglobulin A (IgA) deficiency
IgC2 deficiency T lymphocytes
Thymic hypoplasia (DiGeorge syndrome)
Chronic mucocutaneous candidiasis
B and T lymphocytes
Ataxia-telangiectasia
Nezelof’s syndrome
Complement system
Bacterial infections, infection with Giardia lamblia Pernicious anemia Chronic respiratory infections Predisposition to recurrent infections, adverse reactions to blood transfusions or immunoglobulin, autoimmune diseases, hypothyroidism Heightened incidence of infectious diseases Recurrent infections; hypoparathyroidism; hypocalcemia, tetany, convulsions; congenital heart disease; possible renal abnormalities; abnormal facies Candida albicans infections of mucous membrane, skin, and nails; endocrine abnormalities (hypoparathyroidism, Addison’s disease) Ataxia with progressive neurologic deterioration; telangiectasia (vascular lesions); recurrent infections; malignancies Severe infections; malignancies
Wiskott-Aldrich syndrome
Thrombocytopenia, resulting in bleeding; infections; malignancies
Severe combined immunodeficiency disease (SCID)
Overwhelming severe fatal infections soon after birth (also includes opportunistic infections) Episodes of edema in various parts of the body, including respiratory tract and bowels Lysis of erythrocytes due to lack of decay-accelerating factor (DAF) on erythrocytes
Angioneurotic edema
Paroxysmal nocturnal hemoglobinuria (PNH)
Pooled immunoglobulin Thymus graft
Antifungal agents: Topical: miconazole Oral: clotrimazole, ketoconazole IV: amphotericin B Antimicrobial therapy; management of presenting symptoms; fetal thymus transplant, IV immunoglobulin Antimicrobial therapy; IV immunoglobulin, bone marrow transplantation; thymus transplantation; thymus factors Antimicrobial therapy; splenectomy with continuous antibiotic prophylaxis; IV immunoglobulin and bone marrow transplantation Antimicrobial therapy; IV immunoglobulin and bone marrow transplantation Pooled plasma, androgen therapy
None
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Chart 51-1
Unit 11
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The 10 Warning Signs of Primary Immune Deficiency Primary immune deficiency causes children and adults to have infections that come back frequently or are unusually hard to cure. In America alone, up to 1/2 million people suffer from one or more of the 70 known primary immune deficiency diseases. If you or your child is affected by more than one of the following conditions, speak to your doctor about the possible presence of primary immune deficiency.
1
Eight or more new ear infections within 1 year.
Recurrent, deep skin or organ abscesses.
6
2
Two or more serious sinus infections within 1 year.
Persistent thrush in mouth or elsewhere on skin, after age 1.
7
3
Two or more months on antibiotics with little effect.
Need for intravenous antibiotics to clear infections.
8
4
Two or more pneumonias within 1 year.
5
Failure of an infant to gain weight or grow normally.
Two or more deep-seated infections such as meningitis, osteomyelitis, 9 cellulitis, or sepsis. A family history of primary immune deficiency.
10
Though the primary immune deficiency diseases can be serious, they are rarely fatal and can generally be controlled. Primary immune deficiency should not be confused with AIDS. Primary immune deficiency can be diagnosed through blood tests and should be detected as soon as possible to prevent avoidable permanent damage. As with all disease, only direct examination by a physician should be used to determine the presence of primary immune deficiency. Educational materials developed by the Jeffrey Modell Foundation Medical Advisory Board, New York, NY. Used with permission.
prove successful because these proteins draw nonlymphoid stem cells from the bone marrow and hasten their maturation.
B-CELL DEFICIENCIES Pathophysiology Two types of inherited B-cell deficiencies exist. The first type results from lack of differentiation of B-cell precursors into mature B cells. As a result, plasma cells are lacking, and the germinal centers from all lymphatic tissues disappear, leading to a complete lack of antibody production against invading bacteria, viruses, and other pathogens. Infants born with this disorder suffer from severe infections starting soon after birth. This syndrome is called sex-linked agammaglobulinemia (Bruton’s disease) because all antibodies disappear from the patient’s plasma. B cells in the peripheral blood and the immunoglobulins IgG, IgM, IgA, IgD, and IgE are low or absent. The prevalence of this disorder is approximately 1 case per 100,000 population (Parslow, Stites, Terr & Imboden, 2001). The second type of B-cell deficiency results from a lack of differentiation of B cells into plasma cells. Only diminished an-
tibody production occurs with this disorder. Although plasma cells are the most vigorous producers of antibodies, affected patients have normal lymph follicles and many B lymphocytes that produce some antibodies. This syndrome, called hypogammaglobulinemia, is a frequently occurring immunodeficiency. It is also called common variable immunodeficiency (CVID), a term that encompasses a variety of defects ranging from immunoglobulin A (IgA) deficiency, in which only the plasma cells that produce IgA are lacking, to the other extreme, in which there is severe panhypoglobulinemia (general lack of immunoglobulins in the blood). CVID is the most common primary immunodeficiency seen in adults; it can occur in either gender. Although it can occur at any age, its onset is most often in the second decade of life. The vast majority of patients do not become symptomatic until 15 to 35 years of age. The major immunologic features of CVID include recurrent pyogenic infections, an increased incidence of autoimmune diseases, and a decreased level of total immunoglobulins, with IgG below 250 mg/dL. The B-cell numbers usually remain normal. The etiology of this disorder is unknown and believed to be multifactorial. The prevalence of CVID is about
1 LINE S
SHORT
Chapter 51 1 case per 80,000 population in the United States (Tierney, McPhee & Papdakis, 2001).
Clinical Manifestations Infants with sex-linked agammaglobulinemia usually become symptomatic after the natural loss of maternally transmitted immunoglobulins, which occurs at about 5 to 6 months of age. Symptoms of recurrent pyogenic infections usually occur by 5 to 6 months of age. More than half of patients with CVID develop pernicious anemia. Lymphoid hyperplasia of the small intestine and spleen and gastric atrophy detected by biopsy of the stomach are common findings. Other autoimmune diseases, such as arthritis and hypothyroidism, frequently develop in patients with CVID. Those who develop late-onset disease also have an increased incidence of chronic lung disease, hepatitis, gastric cancer, and malabsorption that results in chronic diarrhea (Porth, 2002). CVID must be distinguished from secondary immunodeficiency diseases caused by protein-losing enteropathy, nephrotic syndrome, or burns. Patients with CVID are susceptible to infections with encapsulated bacteria, such as Haemophilus influenzae, Streptococcus pneumoniae, and Staphylococcus aureus. Frequent respiratory tract infections typically lead to chronic progressive bronchiectasis and pulmonary failure. Commonly, infection with Giardia lamblia occurs. Opportunistic infections with Pneumocystis carinii, however, are seen only in patients who have a concomitant deficiency in T-cell immunity.
Assessment and Diagnostic Findings Sex-linked agammaglobulinemia may be diagnosed by the marked deficiency or complete absence of all serum immunoglobulins. The diagnosis of CVID is based on the history of bacterial infections, quantification of B-cell activity, and reported signs and symptoms. The number of B lymphocytes and the total and specific immunoglobulin levels are measured. Total serum globulin level alone is an inadequate measure because a compensatory overproduction of one globulin may mask the loss of a missing globulin or one present in very low amounts. Antibody titers to confirm successful childhood vaccination are determined by specific serologic tests. Previous successful childhood immunization indicates that B cells were functioning adequately earlier in life. If the patient exhibits signs and symptoms suggestive of pernicious anemia, hemoglobin and hematocrit levels are also obtained.
Medical Management Patients with primary phagocytic disorders may be treated with intravenous immunoglobulin (IVIG). Those who are receiving adequate treatment with IVIG usually do not require prophylactic antibiotics unless they also have chronic respiratory disease. Antimicrobial therapy is prescribed for respiratory infections to prevent complications such as pneumonia, sinusitis, and otitis media. Intestinal infestation with G. lamblia is treated with a 10-day course of metronidazole (Flagyl) or a 7-day course of quinacrine hydrochloride (Atabrine) (Parslow et al., 2001). Patients with pernicious anemia receive parenteral
Management of Patients With Immunodeficiency
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injections of vitamin B12 at monthly intervals. Management may also include physical therapy with postural drainage for patients with chronic lung disease or bronchiectasis (Parslow et al., 2001).
T-CELL DEFICIENCIES Pathophysiology Defects in T cells lead to opportunistic infections. Most primary T-cell immunodeficiencies are genetic in origin. An increased susceptibility to infection is common. Symptoms can vary considerably depending on the type of T-cell defect. Because the T cells play a regulatory role in immune system function, the loss of T-cell function is usually accompanied by some loss of B-cell activity. DiGeorge syndrome, or thymic hypoplasia, is one example of a primary T-cell immunodeficiency. This rare congenital disease results from the absence of several genes on chromosome 22 (Porth, 2002). The variation in symptoms is a result of differences in the amount of genetic material affected. T-cell deficiency occurs when the thymus gland fails to develop normally during embryogenesis. DiGeorge syndrome is one of the few immunodeficiency disorders with symptoms that present almost immediately following birth (Parslow et al., 2001). Chronic mucocutaneous candidiasis with or without endocrinopathy is another T-cell disorder associated with a selective defect in T-cell immunity; it is thought to be caused by an autosomal recessive inheritance, affecting both males and females. It is considered an autoimmune disorder in which the thymus and other endocrine glands are involved in the autoimmune process. The disease causes extensive morbidity resulting from endocrine dysfunction.
Clinical Manifestations Infants born with DiGeorge syndrome have hypoparathyroidism with resultant hypocalcemia resistant to standard therapy, congenital heart disease, characteristic facial features, and possibly renal abnormalities. These infants, susceptible to yeast, fungal, protozoan, and viral infections, are particularly susceptible to childhood diseases (chickenpox, measles, and rubella), which are usually severe and may be fatal. Many of these infants are also born with congenital heart defects, which can result in congestive heart failure. The most frequent presenting sign in patients with DiGeorge syndrome is hypocalcemia that is resistant to standard therapy. It usually occurs within the first 24 hours of life (Parslow et al., 2001). The initial presentation of chronic mucocutaneous candidiasis may be either chronic candidal infection or idiopathic endocrinopathy. Patients may survive to the second or third decade of life. Problems may include hypocalcemia and tetany secondary to hypofunction of the parathyroid glands. Hypofunction of the adrenal cortex (Addison’s disease) is the major cause of death in these patients; it may develop suddenly and without any history of previous symptoms.
Assessment and Diagnostic Findings The status of T cells can be evaluated by peripheral blood lymphocyte counts. Because T cells constitute 65% to 85% of peripheral blood lymphocytes, lymphopenia may signify a T-cell
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deficit. Dermal sensitization of the patient or stimulation of the patient’s T cells in vitro may be conducted to determine if the T cells are capable of producing the expected responses. Immunoglobulin evaluation is not useful in infants because of the presence of maternally transmitted immunoglobulin (Parslow et al., 2001).
Medical Management Patients with T-cell deficiency should receive P. carinii prophylaxis. General care includes management of hypocalcemia and correction of cardiac abnormalities. Hypocalcemia is controlled by oral calcium supplementation in conjunction with vitamin D or parathyroid hormone administration. Congenital heart disease frequently results in heart failure, and these patients may require immediate surgical intervention in a tertiary pediatric center. Transplantation of the fetal thymus, postnatal thymus, and human leukocyte antigen (HLA)-matched bone marrow has been used for permanent reconstitution of T-cell immunity. IVIG therapy may be used if an antibody deficiency exists. This therapy may also be used to control recurrent infections. Prolonged survival has been reported following the successful transplantation of the thymus gland or spontaneous remission of immunodeficiency, which occurs in some patients (Parslow et al., 2001).
COMBINED B-CELL AND T-CELL DEFICIENCIES Pathophysiology Combined B-cell and T-cell deficiencies are those disorders of the immune system that have elements of dysfunction of both the B cells and T cells. A variety of inherited (autosomal recessive and X-linked) conditions fit this description. These conditions have in common disruption of the normal communication system of B cells and T cells and impairment of the immune response (Porth, 2002). These conditions generally appear early in life. Examples of these deficiencies are discussed below. Ataxia-telangiectasia is an autosomal recessive disorder affecting both T- and B-cell immunity. In 40% of patients with this disease, a selective IgA deficiency exists. IgA and IgG subclass deficiencies, along with IgE deficiencies, have been identified. Variable degrees of T-cell deficiencies are observed and become more severe with advancing age. The disease is associated with neurologic, vascular, endocrine, hepatic, and cutaneous abnormalities. It is accompanied by progressive cerebellar ataxia, telangiectasias, recurrent bacterial infection of the sinuses and lungs, and an increased incidence of cancer (Buckley, 2000). Both B and T cells are missing in severe combined immunodeficiency disease (SCID). SCID is a phenotypic term that is used for a wide variety of congenital and hereditary immunologic defects that are characterized by early onset of infections, defects in both B- and T-cell systems, lymphoid aplasia, and thymic dysplasia. Inheritance of this disorder can be X-linked, autosomalrecessive, or sporadic. The exact incidence of SCID is unknown; it is recognized as a rare disease in most population groups, with an incidence of about 1 case in 1,000,000. This illness occurs in all racial groups and both genders (Parslow et al., 2001). Wiskott-Aldrich syndrome is a variation of SCID compounded by thrombocytopenia (loss of platelets). The prognosis is generally poor because most affected infants develop overwhelming fatal infections.
Clinical Manifestations The onset of ataxia (uncoordinated muscle movement) telangiectasia (vascular lesions caused by dilated blood vessels) usually occurs in the first 4 years of life of those with ataxia-telangiectasia. Many patients, however, remain symptom-free for 10 years or longer. As patients approach the second decade of life, chronic lung disease, mental retardation, neurologic symptoms, and physical disability become severe. Long-term survivors develop progressive deterioration of immunologic and neurologic functions. Some affected patients have reached the fifth decade of life. The primary causes of death in these patients are overwhelming infection and lymphoreticular or epithelial cancer. The onset of symptoms occurs within the first 3 months of life in the majority of patients with SCID with respiratory infections, pneumonia (often secondary to P. carinii), thrush, diarrhea, and failure to thrive. Many of these infections are resistant to treatment. Shedding of viruses such as respiratory syncytial virus or cytomegalovirus from the respiratory and gastrointestinal tracts is persistent. Maculopapular and erythematous skin rashes may occur. Vomiting, fever, and a persistent diaper rash are also common manifestations (Parslow et al., 2001).
Medical Management Treatment of ataxia-telangiectasia includes early management of infections with antimicrobial therapy, management of chronic lung disease with postural drainage and physical therapy, and management of other presenting symptoms. Other treatments include transplantation of fetal thymus tissue and IVIG administration (Chart 51-2). Treatment options for SCID include stem cell and bone marrow transplantation. The ideal donor is an HLA-identical sibling (Parslow et al., 2001). Other treatment regimens include IVIG replacement, administration of thymus-derived factors, and thymus gland transplantation. Gene therapy has been used, but the results have thus far been disappointing. As treatment improves, an increased number of those who previously would have died in infancy may live to adulthood.
Nursing Management As many patients require immunosuppression to ensure engraftment of depleted bone marrow during certain transplantation procedures, nursing care must be exquisite, with attention to preventing the transmission of infection to patients. Use of standard precautions and meticulous hand hygiene is essential in caring for these patients. Reverse isolation procedures, where nurses protect the patient by donning gowns, gloves, caps, and so on, is essential. The patient’s condition must be monitored at all times as a certain number of patients experience reactions to transplantation that can be fatal.
DEFICIENCIES OF THE COMPLEMENT SYSTEM The complement system is an integral part of the immune system, and alterations in normal components of complement can result in increased susceptibility to infectious diseases and to immunemediated disorders (Porth, 2002). Improved techniques to identify the individual components of the complement system have led to a steady increase in the number of deficiencies identified. Disorders of the complement system can be primary or secondary.
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Chart 51-2
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• PHARMACOLOGY
Managing an IV Immunoglobulin Infusion Previously available only for intramuscular injection, immunoglobulin can now be administered for replacement therapy as an IV infusion in greater, more effective doses without painful side effects. How Supplied Immunoglobulin is supplied in a 5% solution or a lyophilized powder with a reconstituting diluent prepared from Cohn fraction II obtained from pools of 1,000 to 10,000 donors. Currently, a number of different IV preparations are approved for use and have been shown to be effective and safe by the Food and Drug Administration. Dosage The optimal dose is that determined by the patient’s response. In most instances, an IV dose of 100 to 400 mg/kg of body weight is administered monthly or more frequently to ensure adequate serum IgG levels. Adverse Effects • Complaints of flank pain, shaking chills, and tightness in the chest, terminating with a slight rise in body temperature • Hypotension (possible with severe reactions) • Anaphylactic reactions Guidelines for Nursing Management • Weigh the patient before treatment. • Obtain vital signs before, during, and after treatment.
C2 and C3 component deficiencies result in diminished resistance to bacterial infections. Angioneurotic edema is caused by an inherited deficiency of the inhibitor of C1 esterase, which opposes the release of inflammatory mediators. A deficiency of this inhibitor results in frequent episodes of urticaria and edema in various parts of the body. Patients with paroxysmal nocturnal hemoglobinuria (PNH) lack decay-accelerating factor (DAF), which is found on erythrocytes (red blood cells). DAF normally protects the erythrocytes from lysis (disintegration). In PNH, the complement component C3b accumulates on the CR1 molecule on the erythrocyte, acts as a binding site for the late-acting component, and allows lysis to occur.
Secondary Immunodeficiencies Secondary immunodeficiencies are more common than primary immunodeficiencies and frequently occur as a result of underlying disease processes or from the treatment of these diseases. Common causes of secondary immunodeficiencies include malnutrition, chronic stress, burns, uremia, diabetes mellitus, certain autoimmune disorders, certain viruses, exposure to immunotoxic medications and chemicals, and self-administration of recreational drugs and alcohol. AIDS, the most common secondary immunodeficiency disorder, is discussed in detail in Chapter 52. Patients with secondary immunodeficiencies have immunosuppression and are often referred to as immunocompromised hosts.
Medical Management Management of secondary immunodeficiencies includes diagnosis and treatment of the underlying disease process. Interventions include eliminating the contributing factors, treating the underlying condition, and using sound principles of infection control.
• Administer the prescribed pretreatment prophylactic aspirin or IV antihistamine, such as diphenhydramine (Benadryl).
• Be aware that corticosteroids may be used to prevent possible severe reactions.
• Administer the IV infusion at a slow rate, not to exceed 3 mL/minute.
• Assess the patient for adverse reactions, including the early signs of anaphylactic shock; prepare to slow the infusion rate if necessary. • Be aware that patients with low gammaglobulin levels have more severe reactions than those with normal levels (eg, patients who receive gammaglobulin for thrombocytopenia or Kawasaki disease). • Keep in mind that patients who have an immunoglobulin A (IgA) deficiency have IgE antibodies to IgA, which requires administration of plasma or immunoglobulin replacement from IgA-deficient patients. Because all IV immunoglobulin preparations contain some IgA, they may cause an anaphylactic reaction in patients with IgE anti-IgA antibodies. • Remember that the risk for transmission of hepatitis, HIV, or other known viruses is extremely low.
Nursing Management for Patients With Immunodeficiencies Nursing management includes assessment, patient teaching, and supportive care. Assessment of the patient for infection and for response to treatment is important if it is to be effective. Nursing care of patients with primary and secondary immunodeficiencies depends on the underlying cause of the immunodeficiency, the type of immunodeficiency, and its severity. Because immunodeficiencies result in a compromised immune system and high risk for infection, careful assessment of the patient’s immune status is essential. The assessment focuses on history of past infections, particularly the type and frequency of infection; signs and symptoms of any current skin, respiratory, gastrointestinal, or genitourinary infection; and measures that prevent infection. The nurse monitors the patient for signs and symptoms of infection: fever; chills; cough with or without sputum; shortness of breath; difficulty breathing; difficulty swallowing; white patches in the oral cavity; swollen lymph nodes; nausea; vomiting; persistent diarrhea; frequency, urgency, or pain on urination; redness, swelling, or drainage from skin wounds; lesions on the face, lips, or perianal area; persistent vaginal discharge with or without perianal itching; and persistent abdominal pain. Because the inflammatory response may be blunted, the patient is monitored for subtle and unusual signs and changes in physical status. Vital signs and the development of pain, neurologic signs, cough, and skin lesions are monitored and reported. Pulse rate and respiratory rate should be counted for a full minute, as even subtle changes can signal deterioration in the patient’s clinical status. Thorough auscultation and assessment of the breath sounds are also key in detecting changes in respiratory status. Any unusual response to treatment and any significant change in the patient’s clinical condition are promptly reported to the physician.
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NURSING RESEARCH PROFILE 51-1
Substance P and Anxiety Levels Fehder, W. P., Sachs, J., Uvaydova, M., & Douglas, S. D. (1997). Substance P as an immune modulator of anxiety. Neuroimmunomodulation, 4(1), 42–48.
Purpose Proinflammatory peptide substance P (SP), a protein that is widely distributed in the central and peripheral nervous systems, has been implicated in modulation of the immune and hematopoietic systems. Studies have demonstrated that peripheral blood concentrations of SP have increased in response to psychological anxiety in humans. The purposes of this study were to 1) examine changes in SP levels in peripheral blood in response to anxiety over time, and 2) correlate changes in percentages of CD8-expressing T lymphocytes with alterations in measures of anxiety and SP. Study Sample and Design Two groups of patients were included in the sample in an effort to have two groups of patients receiving similar diagnostic procedures but with different levels of anxiety. Subjects (n = 11) in one group underwent colonoscopy with sedation and subjects (n = 12) in the second group underwent sigmoidoscopy without sedation. It was expected that the patients who received sedation would have lower levels of anxiety than the nonsedated group. Anxiety was assessed by the Multiple Affect Adjective Checklist-Revised state forms (MAACL-R), which were administered to patients prior to the diagnostic procedure, after the diagnostic procedure, and at a home visit 3 days after the procedure. At the same times that the MAACL-R was administered, blood samples were collected. A competitive solid-phase, enzyme-linked immunoabsorbent assay was used to measure blood levels of SP. Flow cytometry was used to express the percentage of mononuclear cells bearing the specific marker. Data from the two groups were compared using repeated-measure analysis of variance (ANOVA) with post-hoc t test and Pearson’s cor-
The nurse also monitors laboratory values (ie, white blood cell count and differential cell count) for changes indicating infection. Culture and sensitivity reports from wound drainage, lesions, sputum, stool, urine, and blood are monitored to identify pathogenic organisms and appropriate antimicrobial therapy. Changes in laboratory results and subtle changes in clinical status must be reported to the physician because the immunocompromised patient may not develop typical signs and symptoms of infection. Assessment also focuses on nutritional status; stress level and coping skills; use of alcohol, drugs, or tobacco; and general hygiene, all of which may affect immune function. Strategies the patient has used to reduce risk for infection are identified. Other aspects of nursing care are directed toward reducing the patient’s risk for infection, assisting with medical measures aimed at improving immune status and treating infection, improving the nutritional status, and maintaining bowel and bladder function. These include careful hand hygiene, encouraging the patient to cough and perform deep-breathing exercises at regular intervals, and protecting the integrity of the skin and mucous membranes. All health care personnel must use strict aseptic technique when performing invasive procedures, such as dressing changes, venipunctures, and bladder catheterizations. Other aspects of nursing care include assisting the patient in managing stress and in adopting a lifestyle that enhances immune system function. If the patient is a candidate for any of the newer or experimental therapies (gene therapy, bone marrow transplantation, immunomodulators such as interferon gamma), the patient or
relation coefficients. A p value of < 0.05 was used to determine statistical significance. Findings Data analysis revealed no significant differences between the anxiety levels of the two groups of patients before, immediately after, and 3 days after the procedures. As patients in both groups experienced high levels of preprocedure anxiety, the researchers divided the subjects into anxiety groups on the basis of the initial anxiety scores using a median split technique. SP levels were then examined by high and low levels of anxiety by repeated-measures ANOVA. The highanxiety group had significantly higher SP levels than the low-anxiety group. Post-hoc t tests revealed SP levels were significantly elevated in the high-anxiety group compared with the low-anxiety group both before and after the procedures. Blood levels of SP, once elevated, remained elevated after the cause of the initial anxiety was removed. Levels of SP in the peripheral blood were found to be significantly correlated with the percent and absolute numbers of CD8 and T lymphocytes. Nursing Implications This study demonstrated that peripheral blood levels of SP may be influenced by levels of anxiety. These findings suggest that patients’ anxiety level may have an effect on their immune system; therefore, nurses need to monitor anxiety levels in patients preparing for diagnostic and other procedures and design and implement measures to alleviate such anxiety-provoking situations. Such interventions may prevent changes in the immune system secondary to anxiety.
parents (if the patient is a child) must be informed about the potential risks and benefits of the treatment regimen. A major role of the nurse is to assist the patient and family to understand the treatment options and to cope with the uncertainties of treatment outcomes. PROMOTING HOME AND COMMUNITY-BASED CARE Teaching Patients Self-Care. The patient and the caregivers are instructed about the signs and symptoms that indicate infection. The nurse explains that the immunosuppressed patient may also have atypical symptoms secondary to underlying immunosuppression. Patients should be advised that they know themselves best; therefore, whenever they experience a symptom that is not typical for them, they should contact their health care provider. The health care provider will then determine and initiate indicated therapy. The patient and caregiver need instruction about any prophylactic medication regimen, including dosage, indications, times, actions, and side effects. The patient is instructed about the importance of avoiding others with infections and avoiding crowds. The patient and family also need to learn about other ways to prevent infection (Chart 51-3). The patient who is to receive IVIG at home will need information about the expected benefits and outcomes of the treatment as well as expected adverse reactions and their management (Chart 51-4). Patients who can perform self-infusion at home are instructed in sterile technique, medication dosages, administration rate, and detection and management of adverse reactions.
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Chart 51-3 Home Care Checklist • Infection Prevention for the Patient With Immunodeficiency At the completion of the home care instruction, the patient or caregiver will be able to: Patient • Identify signs and symptoms of infection to report to the health care provider, such as fever, chills; wet or dry cough; breathing problems; white patches in the mouth; swollen glands; nausea; vomiting; persistent abdominal pain; persistent diarrhea; problems with urination; red, swollen, or draining wounds; sores or lesions on the body; and persistent vaginal discharge with or without itching. ✓ ✓ • Demonstrate correct handwashing procedure. • State rationale for thorough handwashing before eating, after using the bathroom, and before and after performing health care procedures. ✓ ✓ • State rationale for use of cream and emollients to prevent or manage dry, chaffed, or cracked skin. ✓ • Demonstrate recommended personal hygiene in bathing and foot care to prevent bacterial and fungal diseases. ✓ • State rationale for avoiding contact with people who have known illness or who have recently been vaccinated. ✓ • Verbalize understanding of ways to maintain a well-balanced diet and adequate calories. • State the reason for avoiding the eating of raw fruits and vegetables, cooking all foods thoroughly, and immediately refrigerating all leftover food. ✓ ✓ • Identify the rationale for frequent cleaning of kitchen and bathroom surfaces with disinfectant. ✓ • Identify rationale and benefits of avoiding alcohol, tobacco, and unprescribed medications. ✓ • State rationale for taking prescribed medications as directed. ✓ • Verbalize ways to cope with stress successfully, plans for regular exercise, and rationale for obtaining adequate rest.
The patient and family must be instructed to monitor for subtle changes in physical status and must be informed of the importance of seeking immediate health care if changes occur. Patients and their families are also instructed about the importance of continuing the treatment regimen and assisted in incorporating it into their lives. Continuing Care. The importance of follow-up appointments is emphasized to the patient and family. They are urged to notify the primary health care provider about early signs and symptoms of infection, including any subtle changes. The importance of continuing disease-prevention strategies is stressed because these strategies need to be followed lifelong. The patient should be encouraged to have recommended health screening because of the increased susceptibility for cancer secondary to the immune suppression. If the patient’s treatment includes IVIG and the patient or family cannot administer it, a referral for home care or an infusion service may be warranted.
?
Caregiver
✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓
Critical Thinking Exercises
1.
Intravenous immunoglobulin (IVIG) infusions have been prescribed for your patient, who has an immunodeficiency. He tells you that he is very fearful that he may contract hepatitis, HIV infection, AIDS, and other bloodborne diseases from the infusion. How would you respond to these fears and concerns?
2.
You are scheduled to make a home care visit to a patient who was recently discharged from the hospital for an opportunistic infection secondary to AIDS. Upon arrival at the patient’s home, you note a very unkempt environment, with many cats roaming around and several other unsanitary conditions. Explain the course of action that you would take to address these issues, given the patient’s diagnosis and condition.
Chart 51-4 Home Care Checklist • Home Infusion of Intravenous Immunoglobulin (IVIG) At the completion of the home care instruction, the patient or caregiver will be able to: • Identify the benefits and expected outcome of IVIG. • Demonstrate how to check for patency of IV access device. • Demonstrate how to prepare IVIG. • Demonstrate how to infuse IVIG. • Demonstrate how to clean and maintain IV equipment. • Identify side effects and adverse effects of IVIG. • State rationale for prophylactic use of aspirin and an antihistamine before treatment begins. • Verbalize understanding of emergency measures for anaphylactic shock.
Patient
Caregiver
✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓
✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓
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3.
Describe the teaching plan you would use to instruct a patient with an immunodeficiency disorder about prevention and management of infection. How would you modify your approach if the patient did not believe in medications or vaccinations? Are vaccinations recommended in a patient with an underlying immunodeficiency disease? If not, why not?
REFERENCES AND SELECTED READINGS Books Abbas, A. K., & Lichtman, A. H. (2001). Basic immunology. Philadelphia: W. B. Saunders. Antel, P., Birnbaum, G., & Hartung, H. P. (1998). Clinical neuroimmunology. Malden, MA: Blackwell Scientific. Delves, P. J. (1998). Encyclopedia of immunology (2nd ed.). San Diego: Academic Press. Descotes, J., & Bernard, C. (1999). An introduction to immunotoxicology. Philadelphia: Taylor & Francis. Nakamura, R. M., et al. (Eds.) (1998). Clinical diagnostic immunology: Protocols in quality assurance and standardization. Malden, MA: Blackwell Scientific. Parslow, G. G., Stites, D. P., Terr, A. I., & Imboden, J. B. (2001). Medical immunology. New York: McGraw-Hill. Porth, C. M. (2002). Pathophysiology: Concepts of altered health states. Philadelphia: Lippincott Williams & Wilkins. Rich, R. R., Fleisher, T. A., Schwartz, B. D., et al. (2001). Clinical immunology: Principles and practice (2d ed.). St. Louis: Mosby, Inc. Roitt, I. M., & Delves, P. J. (2001). Roitt’s essential immunology. Malden, MA: Blackwell Science. Seidel, H. M., Ball, J. W., Dains, J. E., & Benedict, G. W. (1999). Mosby’s guide to physical examination (4th ed). St. Louis: Mosby, Inc. Tierney, L. M. Jr., McPhee, S. J., & Papadakis, M. A. (2001). Current medical diagnosis and treatment. Stamford, CT: Appleton & Lange. Virella, G. (Ed.). (2001). Medical immunology. New York: Marcel Dekker.
Journals Asterisks indicate nursing research articles. Alcoser, P. W., & Burchett, B. A. (1999). Bone marrow transplantation. Immune system suppression and reconstitution. American Journal of Nursing, 99(6), 26–31.
Buckley, R. H., Schiff, S. E., Schiff, R. I., et al. (1999). Hematopoietic stem-cell transplantation for the treatment of severe combined immunodeficiency. New England Journal of Medicine, 340(7), 508–516. Buckley, R. H. (2000). Primary immunodeficiency diseases due to defects in lymphocytes. New England Journal of Medicine, 343(18), 1313–1324. Davis, J., Krasnewich, D., & Puck, J. M. (2000). Genetic testing and screening in pediatric populations. Nursing Clinics of North America, 35(3), 643–650. *Fehder, W. P. (1999). Alterations in immune response associated with anxiety in surgical patients. CRNA: Clinical Forum for Nurse Anesthetists, 10(3), 124–129. *Fehder, W. P., Sachs, J., Uvaydova, M., & Douglas, S. D. (1997). Substance P as an immune modulator of anxiety. Neuroimmunomodulation, 4(1), 42–48. Fleisher, T. A. (1997). Introduction to diagnostic laboratory immunology. Journal of American Medical Association, 278(22), 1823–1834. Huston, D. P. (1997). The biology of the immune system. Journal of American Medical Association, 278(22), 1804–1822. Lekstrom-Himes, J. A., & Gallin, J. I. (2002). Immunodeficiency diseases caused by defects in phagocytes. New England Journal of Medicine, 343(23), 1703–1714. Smith, J. K., Krishnaswamy, G. H., Dykes, R., et al. (1997). Clinical manifestations of IgE hypogammaglobulinemia. Annals of Allergy, Asthma, and Immunology, 78(3), 313–318.
RESOURCES AND WEBSITES Centers for Disease Control and Prevention, 1600 Clifton Road, Atlanta, GA 30333; (404) 639-3311 or (800) 311-3435; http:// www.cdc.gov. National Institute of Allergy and Infectious Disease, NIAID Office of Communications and Public Liaison, NIH, Building #31, Room 7A50, 31 Center Drive, MSC 2520, Bethesda, MD 20892-2520; (301) 496-5717, http://www.niaid.nih.gov. National Institutes of Health, 9000 Rockville Pike, Bethesda, MD 20892; (301) 496-4000, http://www.nih.gov. National Library of Medicine, 8600 Rockville Pike, Bethesda, MD 20894; (888) FIND-NLM, (888) 346-3656, (301) 594-5983; http://www.nlm.nih.gov.
Chapter
52 ●
Management of Patients With HIV Infection and AIDS
LEARNING OBJECTIVES
●
On completion of this chapter, the learner will be able to: 1. Describe the modes of transmission of HIV infection. 2. Describe the pathophysiology of HIV infection. 3. Explain the physiology underlying the clinical manifestations of 4. 5. 6.
HIV infection. Describe the management of patients with HIV infection. Discuss the nursing interventions appropriate for patients with HIV infection and AIDS. Use the nursing process as a framework for care of the patient with AIDS.
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lthough progress has been made in treating HIV infection and AIDS, the epidemic remains a critical public health issue in all communities across the country and around the world. Prevention, early detection, and ongoing treatment remain important aspects of care for people with HIV infection and AIDS. Nurses in all settings encounter people with this disease; thus, nurses need an understanding of the disorder, knowledge of the physical and psychological consequences associated with the diagnosis, and expert assessment and clinical management skills to provide optimal care for people with HIV infection and AIDS. In 1987, just 6 years after the first cases of AIDS were reported, the U.S. Food and Drug Administration (FDA) approved the first antiretroviral agent; in 1988 the first randomized controlled trial of primary prophylaxis of Pneumocystis carinii pneumonia appeared in the literature; and in 1995 protease inhibitors joined the growing number of antiretroviral agents. Improved treatment of HIV and AIDS has resulted in increased survival times; in 1996, 1997, and 1998, age-adjusted death rates fell 29%, 48%, and 21%, respectively (Lee et al., 2001).
HIV Infection and AIDS Since acquired immunodeficiency syndrome (AIDS) was first recognized more than 20 years ago, remarkable progress has been made in improving the quality and duration of life of persons
with HIV infection. During the first decade, this progress was associated with recognition of opportunistic disease processes, more effective therapy for complications, and introduction of prophylaxis against common opportunistic infections (OIs). The second decade has witnessed progress in developing highly active antiretroviral therapies (HAART) as well as continuing progress in treating OIs (Masur, Kaplan & Holmes, 1999). Since the HIV serologic test (enzyme immunoassay [EIA], formerly enzyme-linked immunosorbent assay [ELISHA]), became available in 1984, allowing early diagnosis of the infection before onset of symptoms, HIV infection has been best managed as a chronic disease and most appropriately managed in an outpatient care setting (Gallant, 2001).
Epidemiology In fall 1982, the Centers for Disease Control and Prevention (CDC) issued a case definition of AIDS after the first 100 cases were reported. Since then, the CDC has revised the case definition a number of times (1985, 1987, and 1993). All 50 states, the District of Columbia, U.S. dependencies and possessions, and independent nations in free association with the United States report AIDS cases to the CDC using a uniform surveillance case definition and case report form (CDC, 2000). Starting in the late 1990s, more states started to implement HIV case reporting in response to the changing epidemic and the need for information on persons with HIV infection who have not developed AIDS.
Glossary alpha-interferon: protein substance that the body produces in response to infection anergy: loss or weakening of the body’s immunity to an irritating agent or antigen B-cell lymphoma: common malignancy in patients with HIV/AIDS candidiasis: yeast infection of skin or mucous membrane CCR5: cell surface molecule that is needed along with the CD4 molecule to fuse with the membranes of the host’s immune system cells cytomegalovirus: a species-specific herpes virus that may cause retinitis in people with AIDS EIA (enzyme immunoassay): a blood test that determines the presence of antibodies to HIV in the blood or saliva; also referred to as enzyme-linked immunosorbent assay (ELISA). Positive results must be validated, usually with Western blot test. HIV-1: retrovirus isolated and recognized as the etiologic agent of AIDS HIV-2: virus closely related to HIV-1 that has also been found to cause AIDS HIV encephalopathy: degenerative neurologic condition characterized by a group of clinical presentations including loss of coordination, mood swings, loss of inhibitions, and widespread cognitive dysfunctions; formerly referred to as AIDS dementia complex (ADC) human papillomavirus (HPV): virus that causes venereal warts Kaposi’s sarcoma: malignancy that involves the epithelial layer of blood and lymphatic vessels
macrophage: large immune cell that devours invading pathogens and other intruders. Can harbor large quantities of HIV without being killed, acting as a reservoir of the virus. monocyte: large white blood cell that ingests microbes or other cells and foreign particles. When a monocyte enters tissues, it develops into a macrophage. Mycobacterium avium complex (MAC): opportunistic infection caused by mycobacterial organisms that commonly causes a respiratory illness but can also infect other body systems opportunistic infection (OI): illness caused by various organisms, some of which usually do not cause disease in persons with normal immune systems p24 antigen: blood test that measures viral core protein; accuracy of test is limited because the p24 antibody binds with the antigen and makes it undetectable peripheral neuropathy: disorder characterized by sensory loss, pain, muscle weakness, and wasting of muscles in the hands or legs and feet Pneumocystis carinii pneumonia (PCP): common opportunistic lung infection caused by an organism, initially thought to be a protozoan but now believed to be a fungus based on its structure polymerase chain reaction (PCR): a sensitive laboratory technique that can detect and quantify HIV in a person’s blood or lymph nodes primary infection: 4- to 7-week period of rapid viral replication immediately follow-
ing infection; also known as acute HIV infection progressive multifocal leukoencephalopathy (PML): opportunistic infection that infects brain tissue and causes damage to the brain and spinal cord protease inhibitor: medication that inhibits the function of protease, an enzyme needed for HIV replication provirus: viral genetic material in the form of DNA that has been integrated into the host genome. When it is dormant in human cells, HIV is in a proviral form. retrovirus: a virus that carries genetic material in RNA instead of DNA and contains reverse transcriptase reverse transcriptase: enzyme that transforms single-stranded RNA into a doublestranded DNA viral load test: measures the quantity of HIV RNA in the blood viral set point: amount of virus present in the blood after the initial burst of viremia and the immune response that follows wasting syndrome: involuntary weight loss of 10% of baseline body weight with chronic diarrhea or chronic weakness and documented fever. Western blot assay: a blood test that identifies antibodies to HIV and is used to confirm the results of an EIA (ELISA) test window period: time from infection with HIV until seroconversion detected on HIV antibody test
Chapter 52 As of December 2001, there were 816,149 reported cases of HIV/AIDS and 506,154 adults, adolescents, and children in the United States (including U. S. dependencies, possessions, and associated nations) living with AIDS. Unprotected sex and sharing of injection drug use equipment are the major means of transmission of HIV. A total of 43,158 AIDS cases were diagnosed in 2001. For men diagnosed with AIDS during 2001, 59% were in the exposure category of men who have sex with men; 24% in injection drug use; and 7% in heterosexual contact. In women diagnosed with AIDS during that same period, 44% reported injection drug use and 52% reported heterosexual contact. Comparing race/ ethnicity among the three largest groups diagnosed in 2001, 20,752 were black, not Hispanic; 11,675 were Caucasian; and 8,221 were Hispanic (CDC, 2002). The number of people living with AIDS is not evenly distributed throughout the United States. States with the largest number of reported AIDS cases during 2001 were New York (7,476), Florida (5,138), California (4,315), Texas (2,892), and Maryland (1,860) (CDC, 2002). AIDS has reached epidemic proportions in some other parts of the world. According to the Joint United Nations Programme on HIV/AIDS, more than 18.8 million people worldwide have died of AIDS and 34.3 million people are infected with HIV, with 5.4 million people newly infected with HIV in 1999 alone (Letvin, Bloom & Hoffman, 2001). UNAIDS (2001) reports that since the epidemic began, more than 60 million people have been infected with the virus, making it the most devastating disease ever. The earliest confirmed case of HIV infection was found in blood drawn from an African man in 1959 (Stephenson, 1998). Although factors associated with the spread of HIV in Africa remain unknown, possibilities include the reuse of unsterilized needles in large-scale vaccination campaigns that began in Africa in the 1960s; however, social changes such as easier access to transportation, increasing population density, and more frequent sexual contacts may have been more important (Stephenson, 1998).
HIV Transmission HIV-1 is transmitted in body fluids containing HIV and/or infected CD4+ (or CD4) T lymphocytes. These fluids include blood, seminal fluid, vaginal secretions, amniotic fluid, and breast milk. Mother-to-child transmission of HIV-1 may occur in utero, at the time of delivery, or through breastfeeding, but transmission frequency during each period has been difficult to determine (Nduati et al., 2000). Any behavior that results in breaks in the skin or mucosa results in the increased probability of exposure to HIV (Chart 52-1). Since HIV is harbored within lymphocytes, a type of white blood cell, any exposure to infected blood results in a significant risk of infection. The amount of virus and infected cells in the body fluid is associated with the risk of new infections. Blood and blood products can transmit HIV to recipients. However, the risk associated with transfusions has been virtually eliminated as a result of voluntary self-deferral, serologic testing, heat treatment of clotting factor concentrates, and more effective virus inactivation methods. Blood donor screening tests detect antibodies to HIV-1 and HIV-2, and p24 antigen testing has been added as an interim measure (American Red Cross, 2001). However, blood donated during the window period will be infectious but will test negative for HIV antibodies. The window period is the period of time between initial infection of HIV and development of a positive antibody test for HIV. Although antibodies will usually be detected within 3 to 6 months, the window period can last up to a year (http://www.cdc.gov/hiv/pubs/pcrs/ pcrs-app.htm).
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Chart 52-1
Risk Factors for HIV Infection and AIDS In the United States, most people with HIV/AIDS have engaged in high-risk behaviors, such as the following: • Intravenous or injection drug use (the term “intravenous drug user” has been replaced by the term “injecting (or injection) drug user.” This term includes people who inject drugs intravenously as well as those who inject drugs intradermally. This method is sometimes referred to as “skin popping.” • Sexual relations with infected individuals (both male and female) Also at risk are people who received blood or blood products contaminated with HIV (especially before blood screening was instituted in 1985) and children born to mothers with HIV infection.
Prevention of HIV Infection Until an effective vaccine is developed, preventing HIV by eliminating or reducing risk behaviors is essential. Primary prevention efforts through effective educational programs are vital for control and prevention. HIV is not transmitted by casual contact. PREVENTIVE EDUCATION Effective educational programs have been initiated to educate the public regarding safer sexual practices to decrease the risk of transmitting HIV-1 infection to sexual partners (Chart 52-2). Latex condoms should be used during vaginal or anal intercourse. Nonlatex condoms are available for people with latex allergy. A condom should be used for oral contact with the penis, and dental dams (a piece of latex used by dentists to isolate a tooth for treatment) should be used for oral contact with the vagina or rectum. As a result of a clinical trial that found that female sex workers who used a nonoxynol-9 (N-9) gel intravaginally in addition to condoms were 50% more likely to be infected with HIV than those who did not use N-9 gel, the CDC issued the recommendation that intravaginal application of N-9 should no longer be recommended as an effective means of HIV prevention (AIDS Institute, 9/21/00). Other topics important in preventive education include the importance of avoiding sexual practices that might cut or tear the lining of the rectum, penis, or vagina and avoiding sexual contact with multiple partners or people who are known to be HIV positive or injection drug users. In addition, people who are HIV positive or use injection drugs should be instructed not to donate blood or share drug equipment with others. Increasingly, needle exchange programs are available to enable injection drug users to obtain sterile drug equipment at no cost. Extensive research has demonstrated that needle exchange programs do not promote increased drug use; on the contrary, they have been found to decrease the incidence of blood-borne infections in persons who use injection drugs (Trzcianowska & Mortensen, 2001). In the absence of needle exchange programs, injection drug users should be instructed on methods to clean their syringes and to avoid sharing cotton and other drug use equipment. RELATED REPRODUCTIVE EDUCATION Because HIV infection in women usually occurs during the childbearing years, family planning issues need to be addressed. Attempts to achieve pregnancy by couples in which one partner has HIV and the other does not expose the unaffected partner to the
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IMMUNOLOGIC FUNCTION
Chart 52-2 Health Promotion and Illness Prevention Safer Sex and Safer Behaviors • Practice abstinence. • Reduce the number of sexual partners to one. • Always use latex condoms; if allergic to latex, use female condoms (nonlatex).
• Do not reuse condoms. • Do not use cervical caps or diaphragms without using a condom as well.
• Always use dental dams for oral female genital or anal • • • • • •
• • •
stimulation. Avoid anal intercourse because this practice may injure tissues. Avoid manual–anal intercourse (“fisting”). Do not ingest urine or semen. Engage in nonpenetrative sex such as body massage, social kissing (dry), mutual masturbation, fantasy, and sex films. Inform prospective sexual and drug-using partners of your HIV-positive status. Notify previous and present sexual partners if you learn that you are HIV seropositive. If you are afraid for your safety, many states have established mechanisms through the public health department in which professionals are available to notify exposed people. If you are HIV seropositive, do not have unprotected sex with another HIV-seropositive person, because cross-infection with another HIV strain can increase the severity of the disease. Do not share needles, razors, toothbrushes, sex toys, or other blood-contaminated articles. If you are HIV seropositive, do not donate blood, plasma, body organs, or sperm.
virus. Efforts at artificial insemination using processed semen from an HIV-infected partner are underway. Studies are needed because HIV has been found in the spermatozoa of patients with AIDS, with possible HIV replication in the male germ cell. Women considering pregnancy need to have adequate information about the risks of transmitting HIV infection to themselves, their partner, and their future children and about the benefits of antiretroviral agents in reducing perinatal HIV transmission. Other than abstinence, the condom has been the only method that has proved to decrease the risk of sexual transmission of HIV infection. Certain contraceptive methods may pose additional health risks for women. Estrogen in oral contraceptives may increase a women’s risk for HIV infection. In addition, women infected with HIV who use estrogen oral contraceptives have shown increased shedding of HIV in vaginal and cervical secretions. The intrauterine contraceptive device (IUD) may also increase the risk for HIV transmission because the device’s string may serve as a means to transmit HIV infection. It also can cause penile abrasions. The female condom is as effective in preventing pregnancy as other barrier methods, such as the diaphragm and the male condom. Unlike the diaphragm, the female condom is also effective in preventing the transmission of HIV infection and sexually transmitted diseases (STDs). The female condom has the distinction of being the first barrier method that can be controlled by women (see Chap. 46).
Transmission to Health Care Providers STANDARD PRECAUTIONS In 1996, efforts were made by the CDC and its Hospital Infection Control Practices Advisory Committee (HICPAC) to stan-
dardize procedures and reduce the risk for exposure through development of Standard Precautions. Standard Precautions incorporate the major features of Universal Precautions (designed to reduce the risk of transmission of blood-borne pathogens) and Body Substance Isolation (designed to reduce the risk of transmission of pathogens from moist body substances); they are applied to all patients receiving care in hospitals regardless of their diagnosis or presumed infectious status (Chart 52-3). Standard Precautions apply to blood; all body fluids, secretions, and excretions, except sweat, regardless of whether they contain visible blood; nonintact skin; and mucous membranes (Hospital Infection Control Practices Advisory Committee [HICPAC], 1996). The primary goal of Standard Precautions is to prevent the transmission of nosocomial infection. The first tier, referred to as Standard Precautions, was developed to reduce the risk for all recognized or unrecognized sources of infections in hospitals. A second tier for infection control precautions for specified conditions, called Transmission-Based Precautions, was designed for use in addition to Standard Precautions for patients with documented or suspected infections involving highly transmissible pathogens. The three types of Transmission-Based Precautions are referred to as Airborne Precautions, Droplet Precautions, and Contact Precautions. They can be used singularly or in combination, but they are always to be used in addition to Standard Precautions (HICPAC, 1997). Large-scale studies of exposed health care workers continue to be conducted by the CDC and other groups. In November 2000, the Needlestick Safety and Prevention Act became law, mandating health care facilities to use devices to protect against sharps injuries (Worthington, 2001). POSTEXPOSURE PROPHYLAXIS FOR HEALTH CARE PROVIDERS Postexposure prophylaxis in response to exposure of health care personnel to blood or other body fluids has been proven to reduce the risk for HIV infection (Worthington, 2001). The CDC (1998) recommends that all health care providers who have sustained a significant exposure to HIV be counseled and offered anti-HIV postexposure prophylaxis, if appropriate. Some clinicians are considering using postexposure prophylaxis for patients exposed to HIV from high-risk sexual behavior or possible contact through injection drug use. This use of postexposure prophylaxis is controversial because of concern that it may be substituted for safer sex practices and safer injection drug use. Postexposure prophylaxis should not be considered an acceptable method of preventing HIV infection. The medications recommended for postexposure prophylaxis are those used to treat established HIV infection. Ideally, prophylaxis needs to start immediately after exposure; therapy started more than 72 hours after exposure is thought to offer no benefit. The recommended course of therapy involves taking the prescribed mediations for 4 weeks. Those who choose postexposure prophylaxis must be prepared for the side effects of the medications and must be willing to face the unknown long-term risks, because HIV often becomes resistant to the medications used to treat it. If the person becomes infected despite prophylaxis, viral drug resistance may reduce future treatment options. The cost is also of concern; the cost of a drug regimen ranges from $500 to more than $1,000, plus the costs of testing and counseling. Health insurance generally does not cover the costs of medications, laboratory tests, and counseling (Chart 52-4).
Chapter 52
Chart 52-3
Management of Patients With HIV Infection and AIDS
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Standard Precautions
The following guidelines were developed to prevent the transmission of infection during patient care for all patients, regardless of known or unknown infectious status. Hand Washing/Hand Hygiene • Wash hands/perform hand hygiene after touching blood, body fluids, secretions, excretions, and contaminated items, whether or not gloves are worn. • Wash hands/perform hand hygiene immediately after gloves are removed, between patient contacts, and when otherwise indicated to avoid transfer of microorganisms to other patients or environments. • Wash hands/perform hand hygiene between tasks and procedures on the same patient to prevent cross-contamination of different body sites. • Use a plain (nonantimicrobial) soap or alcohol-based hand rub for routine hand washing. • Use an antimicrobial agent or waterless antiseptic agent for specific circumstances (control of outbreaks or hyperendemic infections). (See Contact Precautions.) Gloves • Wear clean, nonsterile gloves when touching blood, body fluids, secretions, excretions, and contaminated items. • Put on clean gloves just before touching mucous membranes and nonintact skin. • Change gloves between tasks and procedures on the same patient after contact with materials that may contain a high concentration of microorganisms. • Remove gloves promptly after use, before touching noncontaminated items and environmental surfaces, and before going to another patient. • Wash hands/perform hand hygiene immediately after removing gloves. Mask, Eye Protection, Face Shield • Wear a mask and eye protection or a face shield to protect mucous membranes of the eyes, nose, and mouth during procedures and patient care activities that are likely to generate splashes or sprays of blood, body fluids, secretions, or excretions. Gown • Wear a clean, nonsterile gown to protect skin and prevent soiling of clothing during procedures and patient care activities that are likely to generate splashes or sprays of blood, body fluids, secretions, or excretions. • Select a gown that is appropriate for the activity and amount of fluid likely to be encountered. • Remove a soiled gown as promptly as possible and wash hands/perform hand hygiene to prevent the transfer of microorganisms to other patients or environments. Patient Care Equipment • Handle used patient care equipment soiled with blood, body fluids, secretions, and excretions in a manner that prevents skin
and mucous membrane exposures, contamination of clothing, and transfer of microorganisms to other patients and environments. • Ensure that reusable equipment is not used for the care of another patient until it has been cleaned and reprocessed appropriately. • Ensure that single-use items are discarded properly. Environmental Control • Ensure that the hospital has adequate procedures for the routine care, cleaning, and disinfection of environmental surfaces, beds, bed rails, bedside equipment, and other frequently touched surfaces. • Ensure that procedures are being followed. Linen • Handle, transport, and process used linen soiled with blood, body fluids, secretions, and excretions in a manner that prevents skin and mucous membrane exposures and contamination of clothing and that avoids transfer of microorganisms to other patients and environments. Occupational Health and Bloodborne Pathogens • Take care to prevent injuries when using needles, scalpels, and other sharp instruments or devices: When handling sharp instruments after procedures When cleaning used instruments When disposing of used needles • Never recap used needles or otherwise manipulate them by using both hands or use any technique that involves directing the point of the needle toward any part of the body. • Use either a one-handed scoop technique or a mechanical device designed for holding the needle sheath. • Do not remove used needles from disposable syringes by hand and do not bend, break, otherwise manipulate used needles by hand. • Place used disposable syringes and needles, scalpel blades, and other sharp items in appropriate puncture-resistant containers as close as practical to the area in which the items were used. • Place reusable syringes and needles in a puncture-resistant container for transport to the reprocessing area. • Use mouthpieces, resuscitation bags, or other ventilation devices as an alternative to mouth-to-mouth resuscitation methods in areas where the need for resuscitation is predictable. Patient Placement • Place a patient who contaminates the environment or who does not or cannot be expected to assist in maintaining appropriate hygiene or environmental control in a private room. • If a private room is not available, consult with infection control professionals regarding patient placement or other alternatives.
Adapted from (1996) Guideline for isolation precautions in hospitals. Infection Control and Hospital Epidemiology, 17, 53–80 and (2002). Guideline for hand hygiene in health-care settings. Morbidity and Mortality Weekly Report, 51(RR-16), 1–45.
Pathophysiology Since HIV infection is an infectious disease, it is important to understand how HIV integrates itself into a person’s immune system and how immunity plays a role in the course of infection. This knowledge is also essential for understanding drug therapy and vaccine development.
Viruses are intracellular parasites. HIV belongs to a group of viruses known as retroviruses. These viruses carry their genetic material in the form of ribonucleic acid (RNA) rather than deoxyribonucleic acid (DNA). As can be seen in Figure 52-1, HIV consists of a viral core containing the viral RNA that is surrounded by an envelope consisting of glycoproteins (gp) that protrude. For HIV to enter the targeted cell, the membrane of the
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Chart 52-4
IMMUNOLOGIC FUNCTION CD4+ binding site
1
Postexposure Prophylaxis for Health Care Providers
If you sustain a needlestick injury, take the following actions immediately: • Wash the area with soap and water. • Alert your supervisor and initiate the injury-reporting system used in the setting. • Identify the source patient, who may need to be tested for HIV, hepatitis B, and hepatitis C. (State laws will determine if written informed consent must be obtained from the source patient prior to his or her testing.) • Report to the employee health services, the emergency department, or other designated treatment facility. • Give consent for baseline testing for HIV, hepatitis B, and hepatitis C. • Get postexposure prophylaxis for HIV in accordance with CDC guidelines. Start the prophylaxis medications within 2 hours after exposure. Make sure that you are being monitored for symptoms of toxicity. Practice safer sex until follow-up testing is complete. • Follow up with postexposure testing at 6 weeks, 3 months, and 6 months and perhaps 1 year. • Document the exposure in detail for your own records as well as for the employer.
GP120
3
2
Reverse transcriptase
4 Viral polyprotein
5
6 7 8
Worthington, K. (2001). You’ve been stuck: What do you do? American Journal of Nursing, 101(3); 104.
viral envelope must be fused with the plasma membrane of the cell, a process mediated by the envelope glycoproteins of HIV (Wyatt & Sodroski, 1998). The HIV life cycle is complex and consists of a number of steps (Fig. 52-2). First, the HIV GP120 and GP41 attach to the uninfected CD4 cell surface (receptor) and fuse with the cell
GP120 Lipid membrane
FIGURE 52-2
Life cycle of the HIV-1: (1) Attachment of the HIV virus to CD4+ receptor; (2) internalization and uncoating of the virus with viral RNA and reverse transcriptase; (3) reverse transcription, which produces a mirror image of the viral RNA and double-stranded DNA molecule; (4) integration of viral DNA into host DNA using the integrase enzyme; (5) transcription of the inserted viral DNA to produce viral messenger RNA; (6) translation of viral messenger RNA to create viral polyprotein; (7) cleavage of viral polyprotein into individual viral proteins that make up the new virus; and (8) assembly and release of the new virus from the host cell. From Porth, C. (2002). Pathophysiology: Concepts of altered health states (6th ed.). Philadelphia: Lippincott Williams & Wilkins.
GP41
RNA
P18
P 24
Reverse transcriptase
FIGURE 52-1 Structure of the HIV-1 virus. A glycoprotein envelope surrounds the virus, which carries its genetic material in RNA. Knobs, consisting of protein GP120 and GP41, protrude from the envelope. These proteins are essential for binding the virus to the CD4+ T lymphocyte. From Porth, C. (2002). Pathophysiology: Concepts of altered health states (6th ed.). Philadelphia: Lippincott Williams & Wilkins.
membrane. Second, the viral core contents are emptied into the host cell, a process known as uncoating. Third, HIV enzyme reverse transcriptase copies the viral genetic material from RNA into double-stranded DNA. Fourth, double-stranded DNA is spliced into the cellular DNA by the action of another HIV enzyme integrase. Fifth, using the integrated DNA or provirus as a blueprint, the cell makes new viral proteins and viral RNA. Sixth, HIV protease cleaves the new proteins (polyproteins). Seventh, the new proteins join the viral RNA into new viral particles. Finally, new viral particles bud from the cell and start the process all over (Porth, 2002). Perhaps the least understood aspects of the HIV life cycle are the events that occur immediately after entry of the viral core into the host CD4 cell. The process of viral assembly is intimately linked to its subsequent reversal (disassembly). Interactions occur between viral proteins and cellular factors in the cells that produce virus and frequently influence events at the next round of infection (Emerman & Malim, 1998). In resting (nondividing) cells, HIV can apparently survive in a latent state as an integrated provirus that produces few or no viral particles. These resting CD4 T cells can be prodded to churn out new particles if something reactivates
Chapter 52 them (Mellors, 1998). When a T cell that harbors this integrated DNA (also known as provirus) becomes activated against HIV or other microbes, the cell replicates and also unwittingly begins to produce new copies of both RNA and viral proteins (Bartlett & Moore, 1998). Activation of the infected cell may be achieved by antigens, mitogens, select cytokines (tumor necrosis factor-alpha or interleukin-1), or virus gene products of such viruses as cytomegalovirus (CMV), Epstein-Barr virus, herpes simplex virus, and hepatitis. Consequently, whenever the infected T4 cell is activated, HIV replication and budding occur, which often destroys the host cell. Newly formed HIV is then released into the blood plasma and infects other CD4+ cells (see Fig. 52-1). HIV-1 mutates quickly, at a relatively constant rate, with about 1% of the virus’s genetic material changing annually. Over the years, 10 distinct subtypes of HIV-1 have emerged, designated A through J. Subtype B is the dominant subtype in North America and Europe, while subtype D predominates in Africa (Stephenson, 1998). All viruses target specific cells. Lymphocytes consist of three major populations: T cells, B cells, and natural killer cells (Huston, 1997). Mature T cells are phenotypically composed of two major subpopulations defined by cell surface reciprocal expression of CD4 or CD8 (Huston, 1997). Approximately two thirds of peripheral blood T cells are CD4 and approximately one third are CD8. Most people have about 700 to 1,000 CD4 cells/mm3, but as low as 500/mm3 can be considered “normal.” HIV targets cells with the CD4 glycoprotein, which is expressed on the surface of T lymphocytes, monocytes, dendritic cells, and brain microglia (Wyatt & Sodroski, 1998). A major function of CD4 binding is to induce conformational changes in the GP120 glycoprotein of the HIV envelope that contribute to the formation or exposure of the binding site for the chemokine receptors (Wyatt & Sodroski, 1998). Most primary clinical isolates of HIV use the chemokine receptor CCR5 for entry. HIV-1 isolates arising later in the course of infection often use other chemokine receptors such as CXCR4 in addition to CCR5 (Wyatt & Sodroski, 1998). HIV must attach to both the CD4 and CCR5 binding sites in order to infect CD4+ cells. CD4 fits into a recessed pocket in the viral envelope GP120 that may simply be too deep to be easily accessed by antibodies (Balter, 1998). A mutation of CCR5 was identified that is common among Caucasians but not other ethnic groups. About 1% of Caucasians lack functional CCR5 and are highly protected against HIV infection even if exposed (although protection is not absolute); about 18% are not markedly protected against infection but if infected demonstrate significantly slower rates of disease progression (Collman, 1997).
Stages of HIV Disease The stage of HIV disease is based on clinical history, physical examination, laboratory evidence of immune dysfunction, signs and symptoms, and infections and malignancies. The CDC standard case definition of AIDS categorizes HIV infection and AIDS in adults and adolescents on the basis of clinical conditions associated with HIV infection and CD4+ T-cell counts. The classification system (Table 52-1) groups clinical conditions into one of three categories denoted as A, B, or C. PRIMARY INFECTION (ALSO KNOWN AS ACUTE HIV INFECTION OR ACUTE HIV SYNDROME) The period from infection with HIV to the development of antibodies to HIV is known as primary infection. During this period, there is intense viral replication and widespread dissemination of HIV throughout the body. Symptoms associated with the
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viremia range from none to severe flu-like symptoms. During the primary infection period, the window period occurs because a person is infected with HIV but tests negative on the HIV antibody blood test. Although antibodies to the HIV envelope glycoproteins typically can be detected in the sera of HIV-infected individuals by 2 to 3 weeks after infection, most of these antibodies lack the ability to inhibit virus infection. By the time neutralizing antibodies are detected, HIV-1 is firmly established in the host (Wyatt & Sodroski, 1998). During this period, there are high levels of viral replication and the killing of CD4 T cells, resulting in high levels of HIV in the blood and a dramatic drop in CD4 T cell counts from the normal level of at least 800 cells/mm3 of blood. About 3 weeks into this acute phase, individuals may display symptoms reminiscent of mononucleosis, such as fever, enlarged lymph nodes, rash, muscle aches, and headaches. These symptoms resolve within another 1 to 3 weeks as the immune system begins to gain some control over the virus. That is, the CD4 T-cell population responds in ways that spur other immune cells, such as CD8 lymphocytes, to increase their killing of infected, virus-producing cells. The body produces antibody molecules in an effort to contain the virus; they bind to free HIV particles (outside cells) and assist in their removal (Bartlett & Moore, 1998). This balance between the amount of HIV in the body and the immune response is referred to as the viral set point and results in a steady state of infection. During this steady state, which can last for years, the amount of virus in circulation and the number of infected cells equal the rate of viral clearance (Ropka & Williams, 1998). Primary HIV infection, the time during which the viral burden set point is achieved, includes the acute symptomatic and early infection phases. During this initial stage, viral replication is associated with dissemination in lymphoid tissue and a distinct immunologic response. The final level of the viral set point is inversely correlated with disease prognosis; that is, the higher the viral set point, the poorer the prognosis (Cates, Chesney & Cohen, 1997). The primary infection stage is part of CDC category A. HIV ASYMPTOMATIC (CDC CATEGORY A: MORE THAN 500 CD4+ T LYMPHOCYTES/MM3) On reaching a viral set point, a chronic, clinically asymptomatic state begins. Despite its best efforts, the immune system rarely if ever fully eliminates the virus. By about 6 months, the rate of viral replication reaches a lower but relatively steady state that is reflected in the maintenance of viral levels at a kind of “set point.” This set point varies greatly from patient to patient and dictates the subsequent rate of disease progression; on average, 8 to 10 years pass before a major HIV-related complication develops. In this prolonged, chronic stage, patients feel well and show few if any symptoms (Bartlett & Moore, 1998). Apparent good health continues because CD4 T-cell levels remain high enough to preserve defensive responses to other pathogens. HIV SYMPTOMATIC (CDC CATEGORY B: 200 TO 499 CD4+ T LYMPHOCYTES/MM3) Over time, the number of CD4 T cells gradually falls. Category B consists of symptomatic conditions in HIV-infected patients that are not included in the conditions listed in category C. These conditions must also meet one of the following criteria: (1) the condition is due to HIV infection or a defect in cellular immunity, or (2) the condition must be considered to have a clinical course or require management that is complicated by HIV infection. If an individual was once treated for a category B condition and has not developed a category C disease but is now symptomfree, that person’s illness would be considered category B.
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Table 52-1
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IMMUNOLOGIC FUNCTION
• Classification System for HIV Infection and Expanded AIDS Surveillance Case Definition for Adolescents and Adults
DIAGNOSTIC CATEGORIES CD4+ T-Cell Categories
(1) ≥500/µL (2) 200–499/µL (3) 1⬊80 Present in 80% of those with RA Positive RF may also suggest SLE, Sjögren’s syndrome, or mixed connective tissue disease. The higher the titer (number at right of colon), the greater the inflammation.
Tissue Typing HLA-B27 Antigen Measures presence of HLA antigens, which are used for tissue recognition
Negative
Found in 80%–90% of those with ankylosing spondylitis and Reiter’s syndrome.
Serum Creatinine Metabolic waste excreted through the kidneys Erythrocyte Sedimentation Rate (ESR) Measures the rate at which red blood cells settle out of unclotted blood in 1 hour
Hematocrit Measures the size, capacity, and number of cells present in blood Red Blood Cell Count Measures circulating erythrocytes White Blood Cell Count Measures circulating leukocytes VDRL (Venereal Disease Research Laboratory) Measures antibody to syphilis Uric Acid Measures level of uric acid in serum Serum Immunology Antinuclear Antibody (ANA) Measures antibodies that react with a variety of nuclear antigens If antibodies are present, further testing determines the type of ANA circulating in the blood (anti-DNA, anti-RNP).
Anti-DNA, DNA binding Titer measurement of antibody to doublestranded DNA Complement levels—C3, C4 Complement is a protein substance that binds with antigen–antibody complexes for the purpose of lysis. When the number of complexes increases markedly, complement is used for lysis, thus depleting the amount available in the blood. C-Reactive Protein Test (CRP) Shows presence of abnormal glycoprotein due to inflammatory process Immunoglobulin Electrophoresis Measures the values of immunoglobulins
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The elderly person usually has a lifelong pattern of dealing with the stresses of daily life. Depending on the success of that pattern, the elderly person can often maintain a positive attitude and self-esteem when faced with a rheumatic disease, especially when support is available. Previous stress management strategies are assessed. If these strategies have been effective, the patient is encouraged and supported in their use. If the strategies were ineffective, the nurse assists the patient in identifying alternative strategies, encourages use of new strategies, and assesses their effectiveness.
Medical Management A treatment program involving the interdisciplinary team, including the patient, is the basis for managing the rheumatic diseases. The chronic nature of most of these diseases mandates that the patient understand the disease, have the information necessary to make good self-management decisions, and be presented with a therapeutic program that is compatible with his or her lifestyle. Table 54-2 outlines the goals and strategies of basic rheumatic disease management. PHARMACOLOGIC THERAPY Medications are used with the rheumatic diseases to manage symptoms, control inflammation, and in some instances to modify the disease. Useful medications include the salicylates, NSAIDs, and disease-modifying antirheumatic drugs. Table 54-3 reviews the medications often used. Controlling the inflammation related to the disease process will help in managing pain, but this is often a delayed response. Nonopioid medications are often used for pain management, especially early in the treatment program, until other measures can be instituted (Burckhardt, 2001a). Short-term use of lowdose antidepressant medications, such as amitriptyline, may be prescribed to reestablish adequate sleep patterns and improve pain management (Wegner, 2001). NONPHARMACOLOGIC PAIN MANAGEMENT Nonpharmacologic methods of pain management are important. Methods used include therapeutic heat or cold and devices such
Table 54-2
• Goals and Strategies for Rheumatic Diseases
MAJOR GOALS
MANAGEMENT STRATEGY
Suppress inflammation and the autoimmune response
Optimize pharmacologic therapy (anti-inflammatory and disease-modifying agents) Protect joints; ease pain with splints, thermal modalities, relaxation techniques Implement exercise programs for joint motion and muscle strengthening and overall health Make use of adaptive devices and techniques Provide and reinforce patient teaching Emphasize compatibility of therapeutic regimen and lifestyle
Control pain
Maintain or improve joint mobility
Maintain or improve functional status Increase patient’s knowledge of disease process Promote self-management by patient compatible with the therapeutic regimen
as a cane or a wrist splint to protect and support the joint. A combination of methods may be required because different methods often work better at different times.
Exercise and Activity The ongoing nature of most rheumatic diseases makes it important to maintain and, when possible, improve joint mobility and overall functional status. The individualized exercise program is crucial to movement. Table 54-4 summarizes the exercises appropriate for patients with rheumatic diseases. Appropriate programs of exercise have been shown to decrease pain and improve function. A mild analgesic may be suggested prior to exercise for a patient starting a program of exercise. Acute or prolonged pain associated with exercise should be reported to a health care provider for evaluation (Minor & Westby, 2001). The major challenge for the patient and the health care provider is the need to adjust all aspects of treatment according to the activity of the disease. Especially for the patient with an active diffuse connective tissue disease, such as RA or systemic lupus erythematosus (SLE), activity levels may vary from day to day and even within the day itself.
NURSING PROCESS: THE PATIENT WITH A RHEUMATIC DISEASE Assessment The depth and focus of the nursing assessment depend on several factors: the health care setting (clinic or office, home, extended care facility, or hospital), the role of the nurse (home care nurse; nurse practitioner; hospital, clinic, or office nurse), and the needs of the patient. The nurse is often the first of the health care team members to come in contact with the patient. This enables the nurse to assess the patient’s perceptions of the disorder and situation, actions taken to relieve symptoms, plans for treatment, and expectations. The nurse’s assessment may lead to identifying issues and concerns that can be addressed by nursing interventions and, through collaboration with other team members, to achieving the expected patient outcomes. The health history and physical assessment focus on current and past symptoms, such as fatigue, weakness, pain, stiffness, fever, or anorexia, and the effects of these symptoms on the patient’s lifestyle and self-image. Because the rheumatic diseases affect many body systems, the history and physical assessment include a review and examination of all systems, with particular attention given to those areas most commonly affected, including the musculoskeletal system (see Chart 54-1). The patient’s psychological and mental status and social support systems are also assessed, as is his or her ability to participate in daily activities, comply with the treatment regimen, and manage self-care. The information obtained can give insight into the patient’s understanding of the medication regimen and may reveal misuse of medications, noncompliance, or use of potentially harmful unproven remedies. Additional areas assessed include the patient’s understanding, motivation, knowledge, coping abilities, past experiences, preconceptions, and fears. The effects of the disease on the patient’s self-concept and coping abilities are also assessed. The patient’s perception of the condition and its impact influences the decisions, choices, and actions associated with treatment recommendations.
Chapter 54
Table 54-3
Assessment and Management of Patients With Rheumatic Disorders
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• Medications Used in Rheumatic Diseases
MEDICATION
ACTION, USE, AND INDICATION
NURSING CONSIDERATIONS
Salicylates Acetylated aspirin Nonacetylated choline magnesium trisalicylate (Trilisate) choline salicylate (Arthropan) diflunisal (Dolobid) salsalate (Disalcid) sodium salicylate Nonsteroidal Anti-inflammatory Drugs (NSAIDs) diclofenac (Voltaren) etodolac (Lodine) flurbiprofen (Ansaid) ibuprofen (Motrin) indomethacin (Indocin) ketoprofen (Orudis, Oruvail) meclofenamate (Meclomen) meloxicam (Mobic) nabumatone (Relafen) naproxen (Naprosyn) oxaprozin (DayPro) piroxicam (Feldene) sulindac (Clinoril) tolmetin sodium (Tolectin) COX-2 inhibitors celocoxib (Celebrex) rofecoxib (Vioxx) valdecoxib (Bextra) Disease-Modifying Antirheumatic Drugs (DMARDs) Antimalarials hydroxychloroquine (Plaquenil) chloroquine (Aralen) Gold-containing compounds aurothioglucose (Solganol) gold sodium thiomalate (Myochrysine) auranofin (Ridaura)
Action: anti-inflammatory, analgesic, antipyretic Acetylated salicylates are platelet aggregation inhibitors. Anti-inflammatory doses will produce blood salicylate levels of 20–30 mg/dL.
Administer with meals to prevent gastric irritation. Assess for tinnitus, gastric intolerance, GI bleeding, and purpura. Monitor for possible confusion in the elderly.
Action: anti-inflammatory, analgesic, antipyretic, platelet aggregation inhibitor Anti-inflammatory effect occurs 2–4 weeks after initiation. All NSAIDs are useful for short-term treatment of acute gout attack. NSAIDs are alternative to salicylates for firstline therapy in several rheumatic diseases.
Administer NSAIDs with food. Monitor for GI, CNS, cardiovascular, renal, hematologic, and dermatologic adverse effects. Avoid salicylates; use acetaminophen for additional analgesia. Watch for possible confusion in the elderly.
Action: Inhibit only cyclooxygenase-2 (COX-2) enzymes, which are produced during inflammation and spare COX-1 enzymes, which can be protective to the stomach and kidneys Action: Anti-inflammatory, inhibits lysosomal enzymes Slow-acting, onset may take 2–4 months Useful in RA and SLE
Monitoring the same as for other NSAIDs Appropriate for the elderly and patients who are at high risk for gastric ulcers
sulfasalazine (Azulfidine)
Action: Inhibits T- and B-cell activity, suppresses synovitis during active stage of rheumatoid disease Slow-acting, onset may take 3–6 months IM preparations are given weekly for about 6 months, then every 2–4 weeks Action: Anti-inflammatory, reduces lymphocyte response, inhibits angiogenesis Useful in RA, seronegative spondyloarthropathies
penicillamine (Cuprimine)
Action: Anti-inflammatory, inhibits T-cell function, impairs antigen presentation Slow-acting, onset may take 2–3 months Useful in RA and systemic sclerosis
Immunosuppressives methotrexate (Rheumatrex) azathioprine (Imuran) cyclophosphamide (Cytoxan)
Action: Immune suppression, effects DNA synthesis and other cellular effects Have teratogenic potential; azathioprine and cyclophosphamide reserved for more aggressive or unresponsive disease Methotrexate is “gold standard” for RA treatment; also useful in SLE.
Administer concurrently with NSAIDs. Assess for visual changes, GI upset, skin rash, headaches, photosensitivity, bleaching of hair. Emphasize need for ophthalmologic exams (every 6–12 months). Administer concurrently with NSAIDs. Assess for stomatitis, diarrhea, dermatitis, proteinuria, hematuria, bone marrow suppression (decreased WBCs and/or platelets), CBC and urinalysis with every other injection Administer concurrently with NSAIDs. Do not use in patients with allergy to sulfa medications or salicylates. Emphasize adequate fluid intake. Assess for GI upset, skin rash, headache, liver abnormalities, anemia. Administer concurrently with NSAIDs. Assess for GI irritation, decreased taste, skin rash or itching, bone marrow suppression, proteinuria with CBC, and urinalysis every 2–4 weeks. Assess for bone marrow suppression, GI ulcerations, skin rashes, alopecia, bladder toxicity, increased infections. Monitor CBC, liver enzymes, creatinine every 2–4 weeks. Advise patient of contraceptive measures because of teratogenicity. (continued)
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Table 54-3
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IMMUNOLOGIC FUNCTION
• Medications Used in Rheumatic Diseases (Continued)
MEDICATION
ACTION, USE, AND INDICATION
NURSING CONSIDERATIONS
cyclosporine (Neoval)
Action: Immunomodulator Used for severe, progressive RA, unresponsive to other DMARDs Used in combination with methotrexate
Immunomodulators leflunomide (Arava)
Action: Inhibit pyrimidine synthesis; antiinflammatory May be used alone or in combination with other DMARDs. Used in moderate to severe RA. Action: Binds to tumor necrosis factor, a cytokine involved in inflammatory and immune responses. Used in moderate to severe RA unresponsive to methotrexate. May be used in combination with methotrexate Action: Anti-inflammatory, analgesic Used for shortest duration and at lowest dose possible to minimize adverse effects Useful for unremitting RA, SLE, polymyalgia rheumatica, myositis, arteritis Fast-acting; onset in days Injections useful for joints unresponsive to NSAIDs
Assess slow dose titration upward until response noted or toxicity occurs. Assess for toxic effects: bleeding gums, fluid retention, hair growth, tremors. Monitor blood pressure and creatinine every 2 weeks until stable. Long half-life; requires loading dose followed by daily administration. Assess for diarrhea, nausea, rash, alopecia. Contraindicated in pregnancy. Monitor liver function tests. Teach patient subcutaneous self-injection to be administered 2×/week. Monitor for injection site reactions. Educate patient about increased potential for infection and to withhold medication if fever occurs. Assess for toxicity: cataracts, GI irritation, hyperglycemia, hypertension, fractures, avascular necrosis, hirsutism, psychosis. Joints most amenable to injections include ankles, knees, hips, shoulders, and hands. Repeated injections can cause joint damage.
etanercept (Enbrel)
infliximab (Remicade) Corticosteroids prednisone prednisolone hydrocortisone intra-articular injections
Topical Analgesics capsaicin (Zostrix)
Teach patient to apply sparingly, avoid areas of open skin, avoid contact with eyes and mucous membranes. Wash hands carefully after application. Assess for local skin irritation.
Action: analgesic
DMARDs, disease-modifying antirheumatic drugs.
Diagnosis
• Fatigue related to increased disease activity, pain, inadequate
NURSING DIAGNOSES Although many nursing diagnoses are appropriate for the patient with a rheumatic disease, a few of the most common include the following: • Acute and chronic pain related to inflammation and increased disease activity, tissue damage, fatigue, or lowered tolerance level
• • • •
Table 54-4
• Suggested Exercises to Promote Mobility
INFLAMMATORY PROCESS (PAIN)
RECOMMENDED EXERCISE
PATIENT PERFORMANCE LEVEL
Acute exacerbation; severe pain Subacute; moderate or minimal pain
Passive range of motion (ROM) Active assistive or active ROM within pain tolerance
Unable to perform exercises alone Can perform with help from another person or an assistive mechanical device Can perform alone
Inactive; remission; minimal pain or absence of pain
Active ROM: isometrics
•
sleep/rest, deconditioning, inadequate nutrition, emotional stress/depression Disturbed sleep pattern related to pain, depression, and medications Impaired physical mobility related to decreased range of motion, muscle weakness, pain on movement, limited endurance, lack of or improper use of ambulatory devices Self-care deficits related to contractures, fatigue, or loss of motion Disturbed body image related to physical and psychological changes and dependency imposed by chronic illness Ineffective coping related to actual or perceived lifestyle or role changes
COLLABORATIVE PROBLEMS/ POTENTIAL COMPLICATIONS Based on assessment data, potential complications may include the following:
• Adverse effects of medications Planning and Goals The major goals for the patient may include relief of pain and discomfort, relief of fatigue, increased mobility, maintenance of self-care, improved body image, effective coping, and absence of complications.
Chapter 54
Assessment and Management of Patients With Rheumatic Disorders
Nursing Interventions An understanding of the underlying disease process (ie, degeneration or inflammation, including degeneration resulting from inflammation or vice versa) guides the nurse’s critical thinking processes. In addition, knowledge about whether the condition is localized or more widely systemic influences the scope of the nursing activity. Some rheumatic diseases (eg, OA) are more localized alterations in which control of symptoms such as pain or stiffness is possible. Others (eg, gout) have a known cause and specific treatment to control the symptoms. The diseases that usually present the greatest challenge are those with systemic manifestations, such as the diffuse connective tissue diseases. The Plan of Nursing Care details the nursing interventions to be considered for each nursing diagnosis. RELIEVING PAIN AND DISCOMFORT Medications are used on a short-term basis to relieve acute pain. Because the pain may be persistent, nonopioid analgesics such as acetaminophen are often used. After administering medications, the nurse needs to reassess pain levels at intervals. With persistent pain, assessment findings should be compared with baseline measurements and evaluations. Additional measures include exploring coping skills and strategies that have worked in the past. The patient needs to understand the importance of taking medications, such as NSAIDs and disease-modifying agents, exactly as prescribed to achieve maximum benefits. These benefits include relief of pain and anti-inflammatory action as the disease is brought under control. Because disease control and pain relief are delayed, the patient may mistakenly believe the medication is ineffective or may think of the medication as merely “pain pills,” taking them only sporadically and failing to achieve control over the disease activity. Alternately, the patient may not understand the need to continue the medication for its anti-inflammatory actions once pain control has been achieved. A weight reduction program may be recommended to relieve stress on painful joints. Heat applications are also helpful in relieving pain, stiffness, and muscle spasm. Superficial heat may be applied in the form of warm tub baths or showers and warm moist compresses. Paraffin baths (dips), which offer concentrated heat, are helpful to patients with wrist and small-joint involvement. Maximum benefit is achieved within 20 minutes of application. More frequent use for shorter lengths of time is most beneficial. Therapeutic exercises can be carried out more comfortably and effectively after heat has been applied. In some patients, however, heat may actually increase pain, muscle spasm, and synovial fluid volume. If the inflammatory process is acute, cold applications in the form of moist packs or an ice bag may be tried. Both heat and cold are analgesic to nerve pain receptors and can relax muscle spasms. Safe use of heat and cold must be evaluated and taught, particularly to patients with impaired sensation. The use of braces, splints, and assistive devices for ambulation, such as canes, crutches, and walkers, eases pain by limiting movement or stress from weight bearing on painful joints. Acutely inflamed joints can be rested by applying splints to limit motion. Splints also support the joint to relieve spasm. Canes and crutches can relieve stress from inflamed and painful weight-bearing joints while promoting safe ambulation. Cervical collars may be used to support the weight of the head and limit cervical motion. A metatarsal bar or special pads may be put into shoes if foot pain or deformity is present. Other strategies for decreasing pain include muscle relaxation techniques, imagery, self-hypnosis, and distraction.
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DECREASING FATIGUE Fatigue related to rheumatic disease can be both acute (brief and relieved by rest or sleep) and chronic. Chronic fatigue, related to the disease process, is persistent, cumulative, and not eliminated by rest but is influenced by biologic, psychological, social, and personal factors. Disease-related factors that may influence the amount and severity of fatigue include persistent pain, sleep disturbance, impaired physical activity, and disease duration. Pain increases fatigue by requiring additional physical and emotional energy to deal with it. It may also cause the patient to expend more energy to do tasks in a way that causes less pain. Pain may also interfere with sleep, thereby increasing the fatigue level (Aaronson et al., 1999; Wolfe & Skevington, 2000). Efforts are aimed at modifying and reducing the fatigue. Energy may be regained by using rest periods. The patient’s needs determine the type and amount of rest needed. Naps or nighttime sleep can provide systemic rest. Splints can provide articular rest by limiting motion and stress on the joints. Relaxation techniques can provide emotional rest. Inactivity may lead to deconditioning and fatigue, so measures to build endurance should be instituted. Conditioning exercise, such as walking, swimming, or biking, requires gradual progression of activity and monitoring of disease activity. Psychosocial factors with an effect on fatigue include depression, learned helplessness, and perceived social support (Belza, 2001; Parker et al., 2001). These factors affect the patient’s perception and evaluation of the fatigue. Improvement of functional status can improve mood. The patient is taught strategies to conserve energy, such as planning and grouping activities to minimize the number of times the patient needs to climb the stairs each day and sitting down to prepare meals. PROMOTING RESTORATIVE SLEEP Restful sleep is important in helping the patient to cope with pain, minimize physical fatigue, and deal with the changes necessitated by a chronic disease. In patients with acute disease, sleep time is frequently reduced and fragmented by prolonged awakenings. Stiffness, depression, and medications may also compromise the quality of sleep and increase daytime fatigue. A sleep-inducing routine, medication, and comfort measures may help improve the quality of sleep. INCREASING MOBILITY Proper body positioning is essential to minimize stress on inflamed joints and prevent deformities that limit mobility. All joints should be supported in a position of optimal function. When in bed, the patient should lie flat on a firm mattress, with feet positioned against a footboard and with only one pillow under the head because of the risk of dorsal kyphosis. A pillow should not be placed under the knees because this promotes flexion contracture. The patient should lie prone several times daily to prevent hip flexion contracture. Active range-of-motion exercises are encouraged because they prevent joint stiffness. If the patient cannot actively exercise the joints, passive range of motion should be performed. Measures to reinforce proper body posture and increase mobility include walking erect and using chairs with straight backs. When seated, the patient should rest the feet flat on the floor and the shoulders and hips against the back of the chair. (text continues on page 1618)
Plan of Nursing Care Care of the Patient With a Rheumatic Disease Nursing Interventions
Rationale
Expected Patient Outcomes
Nursing Diagnosis: Acute and chronic pain related to inflammation and increased disease activity, tissue damage, or lowered tolerance level Goal: Improvement in comfort level; incorporation of pain management techniques into daily life 1. Provide variety of comfort measures a. Application of heat or cold b. Massage, position changes, rest c. Foam mattress, supportive pillow, splints d. Relaxation techniques, diversional activities 2. Administer anti-inflammatory, analgesic, and slow-acting antirheumatic medications as prescribed. 3. Individualize medication schedule to meet patient’s need for pain management. 4. Encourage verbalization of feelings about pain and chronicity of disease. 5. Teach pathophysiology of pain and rheumatic disease, and assist patient to recognize that pain often leads to unproved treatment methods. 6. Assist in identification of pain that leads to use of unproven methods of treatment. 7. Assess for subjective changes in pain.
1. Pain may respond to non-pharmacologic interventions such as joint protection, exercise, relaxation, and thermal modalities. 2. Pain of rheumatic disease responds to individual or combination medication regimens. 3. Previous pain experiences and management strategies may be different from those needed for persistent pain. 4. Verbalization promotes coping. 5. Knowledge of rheumatic pain and appropriate treatment may help patient avoid unsafe, ineffective therapies.
• Identifies factors that exacerbate or influence pain response
• Identifies and uses pain management strategies
• Verbalizes decrease in pain • Reports signs and symptoms of side effects • • • •
in timely manner to prevent additional problems Verbalizes that pain is characteristic of rheumatic disease Establishes realistic pain-relief goals Verbalizes that pain often leads to the use of nontraditional and unproved selftreatment methods Identifies changes in quality or intensity of pain
6. The impact of pain on an individual’s life often leads to misconceptions about pain and pain management techniques. 7. The individual’s description of the pain sensation is a more reliable indicator than objective measurements such as change in vital signs, body movement, and facial expression.
Nursing Diagnosis: Fatigue related to increased disease activity, pain, inadequate sleep/rest, deconditioning, inadequate nutrition, and emotional stress/depression Goal: Incorporates as part of daily activities strategies necessary to modify fatigue 1. Provide instruction about fatigue a. Describe relationship of disease activity to fatigue. b. Describe comfort measures while providing them. c. Develop and encourage a sleep routine (warm bath and relaxation techniques that promote sleep). d. Explain importance of rest for relieving systematic, articular, and emotional stress. e. Explain how to use energy conservation techniques (pacing, delegating, setting priorities). f. Identify physical and emotional factors that can cause fatigue.
1. The patient’s understanding of fatigue will affect his or her actions. a. The amount of fatigue is directly related to the activity of the disease. b. Relief of discomfort can relieve fatigue. c. Effective bedtime routine promotes restorative sleep.
2. Facilitate development of appropriate activity/rest schedule. 3. Encourage adherence to the treatment program. 4. Refer to and encourage a conditioning program.
2.
5. Encourage adequate nutrition, including source of iron from food and supplements.
5.
3. 4.
• Self-evaluates and monitors fatigue pattern • Verbalizes the relationship of fatigue to disease activity
• Uses comfort measures as appropriate • Practices effective sleep hygiene and routine • Makes use of various assistive devices
d. Different kinds of rest are needed to relieve fatigue and are based on patient need and response. e. A variety of measures can be used to conserve energy.
•
f. Awareness of the various causes of fatigue provides the basis for measures to modify the fatigue. Alternating rest and activity conserves energy while allowing most productivity. Overall control of disease activity can decrease the amount of fatigue. Deconditioning resulting from lack of mobility, understanding, and disease activity contributes to fatigue. A nutritious diet can help counteract fatigue.
• • •
• •
(splints, canes) and strategies (bed rest, relaxation techniques) to ease different kinds of fatigue Incorporates time management strategies in daily activities Uses appropriate measures to prevent physical and emotional fatigue Has an established plan to ensure wellpaced, therapeutic activity schedule Adheres to therapeutic program Follows a planned conditioning program Consumes a nutritious diet consisting of appropriate food groups and recommended daily allowance of vitamins and minerals
(continued) 1616
Chapter 54
Assessment and Management of Patients With Rheumatic Disorders
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Plan of Nursing Care Care of the Patient With a Rheumatic Disease (Continued) Nursing Interventions
Rationale
Expected Patient Outcomes
Nursing Diagnosis: Impaired physical mobility related to decreased range of motion, muscle weakness, pain on movement, limited endurance, lack of or improper use of ambulatory devices Goal: Attains and maintains optimal functional mobility 1. Encourage verbalization regarding limitations in mobility.
2. Assess need for occupational or physical therapy consultation: a. Emphasize range of motion of affected joints. b. Promote use of assistive ambulatory devices. c. Explain use of safe footwear. d. Use individual appropriate positioning/posture. 3. Assist to identify environmental barriers. 4. Encourage independence in mobility and assist as needed. a. Allow ample time for activity b. Provide rest period after activity. c. Reinforce principles of joint protection and work simplification. 5. Initiate referral to community health agency.
1. Mobility is not necessarily related to deformity. Pain, stiffness, and fatigue may temporarily limit mobility. The degree of mobility is not synonymous with the degree of independence. Decreased mobility may influence a person’s selfconcept and lead to social isolation. 2. Therapeutic exercises, proper footwear, and/or assistive equipment may improve mobility. Correct posture and positioning are necessary for maintaining optimal mobility.
• Identifies factors that interfere with mobility • Describes and uses measures to prevent loss of motion
• Identifies environmental (home, school, • •
work, community) barriers to optimal mobility Uses appropriate techniques and/or assistive equipment to aid mobility Identifies community resources available to assist in managing decreased mobility
3. Furniture and architectural adaptations may enhance mobility. 4. Changes in mobility may lead to a decrease in personal safety.
5. The degree of mobility may be slow to improve or may not improve with intervention.
Nursing Diagnosis: Self-care deficits related to contractures, fatigue, or loss of motion Goal: Achieves self-care independently or with the use of resources 1. Assist patient to identify self-care deficits and factors that interfere with ability to perform self-care activities. 2. Develop a plan based on the patient’s perceptions and priorities on how to establish and achieve goals to meet selfcare needs, incorporating joint protection, energy conservation, and work simplification concepts. a. Provide appropriate assistive devices. b. Reinforce correct and safe use of assistive devices. c. Allow patient to control timing of selfcare activities. d. Explore with the patient different ways to perform difficult tasks or ways to enlist the help of someone else. 3. Consult with community health care agencies when individuals have attained a maximum level of self-care yet still have some deficits, especially regarding safety.
1. The ability to perform self-care activities is influenced by the disease activity and the accompanying pain, stiffness, fatigue, muscle weakness, loss of motion, and depression. 2. Assistive devices may enhance self-care abilities. Effective planning for changes must include the patient who must accept and adopt the plan.
• Identifies factors that interfere with the ability to perform self-care activities
• Identifies alternative methods for meeting self-care needs
• Uses alternative methods for meeting selfcare needs
• Identifies and uses other health care
resources for meeting self-care needs
3. Individuals differ in ability and willingness to perform self-care activities. Changes in ability to care for self may lead to a decrease in personal safety. (continued)
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Unit 11
IMMUNOLOGIC FUNCTION
Plan of Nursing Care Care of the Patient With a Rheumatic Disease (Continued) Nursing Interventions
Rationale
Expected Patient Outcomes
Nursing Diagnosis: Disturbed body image related to physical and psychological changes and dependency imposed by chronic illness Goal: Adapts to physical and psychological changes imposed by the rheumatic disease 1. Help patient identify elements of control over disease symptoms and treatment. 2. Encourage patient’s verbalization of feelings, perceptions, and fears. a. Help to assess present situation and identify problems. b. Assist to identify past coping mechanisms. c. Assist to identify effective coping mechanisms.
1. The individual’s self-concept may be altered by the disease or its treatment. 2. The individual’s coping strategies reflect the strength of his or her self-concept.
• Verbalizes an awareness that changes
•
taking place in self-concept are normal responses to rheumatic disease and other chronic illnesses Identifies strategies to cope with altered self-concept
Nursing Diagnosis: Ineffective coping related to actual or perceived lifestyle or role changes Goal: Use of effective coping behaviors for dealing with actual or perceived limitations and role changes 1. Identify areas of life affected by disease. Answer questions and dispel possible myths. 2. Develop plan for managing symptoms and enlisting support of family and friends to promote daily function.
1. The effects of disease may be more or less manageable once identified and explored reasonably. 2. By taking action and involving others appropriately, patient develops or draws on coping skills and community support.
• Names functions and roles affected and not affected by disease process
• Describes therapeutic regimen and states actions to take to improve, change, or accept a particular situation, function, or role
Collaborative Problems: Complications secondary to effects of medications Goal: Experiences absence or resolution of complications 1. Perform periodic clinical assessment and laboratory evaluation. 2. Instruct in correct self-administration, side effects, and importance of monitoring. 3. Counsel regarding methods to reduce side effects and manage symptoms. 4. Administer medications in modified doses as prescribed if complications occur.
1. Skillful assessment helps detect early symptoms of side effects of medications. 2. The patient needs accurate information about medications and side effects to avoid or manage them. 3. Appropriate identification and early intervention may minimize complications. 4. Modifications may help minimize side effects or other complications.
Care must be taken so that splinting for comfort does not restrict mobility later. The knee is splinted at full extension and the wrist at slight dorsiflexion. Because of the predominant strength of flexor muscles, the joints should not be permitted to “freeze” in positions of flexion. This can be prevented by regularly removing the splint and exercising the joint through a range of motion. Splint modification may be needed when changes occur in joint structure. Additionally, assistive devices may be necessary for mobility. They should be properly fitted and the patient should be instructed in their correct and safe use. A cane, long enough to allow for only a slight bend of the elbow, should be held in the hand opposite the affected side. Forearm-trough style crutches (platform crutches) may be needed to protect the upper extremities if the disease also involves the hands and wrists. This is especially important for the patient undergoing rehabilitation after
• Complies with monitoring procedures and experiences minimal side effects
• Takes medication as prescribed and lists potential side effects
• Identifies strategies to reduce or manage side effects
• Reports that side effects or complications have subsided
lower extremity joint reconstructive surgery. Assistive devices can mean the difference between dependence and independence in mobility; however, they may also alter the patient’s body image, which can become a barrier to compliance with treatment. FACILITATING SELF-CARE Adaptive equipment may increase the patient’s independence. When introducing adaptive equipment, however, the nurse should be sensitive to the patient’s feelings by demonstrating acceptance and positive attitudes about using these devices. The nurse needs to keep in mind that a patient’s deformity does not necessarily equate with the severity of limitations or disability. For example, swollen hands may be more limiting than deformed hands. The nurse in the hospital or in the extended care facility can help preserve the patient’s independence in these settings by making available adaptive equipment for eating, toileting,
Chapter 54
Assessment and Management of Patients With Rheumatic Disorders
bathing, and dressing. In the home, the nurse can encourage use of these devices. Again, by relieving pain, stiffness, and fatigue, the nurse may increase the patient’s ability to perform self-care (Luck, 2001). IMPROVING BODY IMAGE AND COPING All aspects of the patient’s life, including perception of self, work role, social life, sexual function, and financial status, may be altered because of the unpredictability and uncertainty of the course of a rheumatic disease. Body image changes may cause social isolation and depression. The nurse and the family need to empathize with the patient’s emotional reactions to the disease. Communication should be encouraged so that the patient and family verbalize feelings, perceptions, and fears related to the disease. The nurse helps the patient and family identify areas in which they have some control over disease symptoms and treatment. The nurse also encourages commitment to the treatment program, which is a key to positive outcomes, as well as use of effective coping strategies. MONITORING AND MANAGING POTENTIAL COMPLICATIONS Medications used for treating rheumatic diseases have the potential for serious and adverse effects. Thus, an important aspect of care is avoiding medication-induced complications. The physician bases the prescribed medication regimen on clinical findings and past medical history, then monitors for side effects with periodic clinical assessments and laboratory testing. The nurse has a major role in working with the physician and pharmacist to help the patient recognize and deal with side effects from medications. These side effects may include gastrointestinal bleeding or irritation, bone marrow suppression, kidney or liver toxicity, infection, mouth sores, rashes, and changes in vision. Other signs and symptoms include bruising, breathing problems, dizziness, jaundice, dark urine, black or bloody stools, diarrhea, nausea and vomiting, and headaches. Systemic and local infections, which can often be masked by high doses of corticosteroids, need close monitoring (see Table 54-3 for more information about administration considerations). Patient instruction also includes teaching correct techniques of self-administration of medications, methods of reducing side effects, and measures to ensure regular monitoring. The nurse can be available for consultation between physician visits. If side
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effects occur, the medication may need to be stopped or the dose reduced. The patient may experience an increase in symptoms while the complication is being resolved or a new medication is being initiated. In such cases, the nurse’s counseling regarding symptom management may relieve potential anxiety and distress. PROMOTING HOME AND COMMUNITY-BASED CARE Teaching Patients Self-Care Patient teaching is an essential aspect of nursing care of the patient with rheumatic disease to enable the patient to maintain as much independence as possible, to take medications accurately and safely, and to use adaptive devices correctly. Patient teaching focuses on the disorder itself, the possible changes related to the disorder, the therapeutic regimen prescribed to treat it, the side effects of medications, strategies to maintain independence and function, and patient safety in the home (Chart 54-2). The patient and family are encouraged to verbalize their concerns and ask questions. Pain, fatigue, and depression can interfere with the patient’s ability to learn and should be addressed before initiating teaching. Various educational strategies may then be used, depending on the patient’s previous knowledge base, interest level, degree of comfort, social or cultural influences, and readiness to learn. The nurse instructs the patient about basic disease management and necessary adaptations in lifestyle. Because suppression of inflammation and autoimmune responses requires the use of anti-inflammatory, disease-modifying antirheumatic and immunosuppressive agents, the patient is taught about prescribed medications, including type, dosage, rationale, side effects, self-administration, and required monitoring procedures. If hospitalized, the patient is encouraged to practice new self-management skills with support from caregivers and significant others. The nurse then reinforces disease management skills during each patient contact. Barriers to compliance are assessed and measures are taken to promote adherence to medications and the treatment program. Continuing Care Depending on the severity of the disorder and the patient’s resources and supports, referral for home care may or may not be warranted. However, the patient who is elderly or frail, has a rheumatic disorder that limits function significantly, and lives alone may need a referral for home care.
Chart 54-2 Home Care Checklist • The Patient with Rheumatic Disease At the completion of the home care instruction, the patient or caregiver will be able to: • Explain the nature of the disease and principles of disease management. • Describe the medication regimen (name of medications, dosage, schedule of administration, precautions, side effects, and desired effects). • Identify monitoring procedures and strategies that should be implemented. • Identify sources of additional information, if necessary. • Demonstrate accurate and safe self-administration of medications. • Describe and demonstrate use of pain management techniques. • Demonstrate use of joint protection techniques in activities of daily living (ADLs). • Demonstrate ability to perform self-care activities independently or with assistive devices. • Demonstrate a safe exercise program. • Demonstrate a relaxation technique.
Patient
Caregiver
✓ ✓
✓ ✓
✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓
✓ ✓ ✓ ✓ ✓
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Unit 11
IMMUNOLOGIC FUNCTION
The impact of rheumatic disease on everyday life is not always evident when the patient is seen in the hospital or an ambulatory care setting. The increased frequency with which nurses see patients in the home provides opportunities for recognizing problems and implementing interventions aimed at improving the quality of life of patients with rheumatic disorders. The patient encountered in the home setting often has a rheumatic disease that is secondary to the primary reason for the visit. In such cases, the problems caused by the rheumatic disease may interfere with the treatment of the primary condition. For example, the patient who is recovering from coronary artery surgery may have been instructed to exercise but is unable or only partially able to do so because of the rheumatic disease. Conversely, treatment of the primary condition may cause or increase problems related to the rheumatic disease. For example, the cardiac patient who has been instructed to walk long distances every day may find that doing so increases the symptoms of OA in the knees. During home visits, the nurse has the opportunity to assess the home environment and its adequacy for patient safety and management of the disorder. Compliance with the treatment program can be more easily monitored in the home setting, where physical and social barriers to adherence are more readily identified. For example, the patient with diabetes who requires insulin may be unable to fill the syringe accurately or administer the insulin because of impaired joint mobility. Appropriate adaptive equipment needed for increased independence is often identified more readily when the nurse sees how the patient functions in the home. Any barriers to compliance can be identified and appropriate referrals made. For patients at risk for impaired skin integrity, the home care nurse can closely monitor skin status and also instruct, provide, or supervise the patient and family in preventive skin care measures. The nurse also assesses the patient’s need for assistance in the home and supervises home health aides, who may meet many of the needs of the patient with a rheumatic disease. Referrals to physical and occupational therapists may be made as problems are identified and limitations increase. A home care nurse can visit the home to make sure the patient can function as independently as possible despite mobility problems and can safely manage treatments and pharmacotherapy. The patient and family should be alerted to support services such as Meals on Wheels and local Arthritis Foundation chapters. Because many of the medications to suppress inflammation are injectable, the nurse may administer the medication to the patient or teach self-injection procedure. These frequent contacts allow the nurse to reinforce other disease management techniques. The nurse also assesses the patient’s physical and psychological status, adequacy of symptom management, and adherence to the management plan. Previous teaching is reinforced with emphasis on side effects of medications and changes in physical status indicating disease progression and the need to contact the health care provider for reevaluation; otherwise, patients may wait until their next appointment. The importance of follow-up appointments is emphasized to the patient and family. Patients with chronic disorders often neglect general health issues if they are focused on their chronic disorder; therefore, the patient and family should be reminded about the importance of participating in other health promotion activities and health screening (eg, immunizations, cholesterol screening, bone density testing, gynecologic examinations, mammography, colonoscopy).
Evaluation EXPECTED PATIENT OUTCOMES Expected patient outcomes may include: 1. Experiences relief of pain or improved comfort level a. Identifies factors that cause or increase pain b. Identifies realistic goals for pain relief c. Uses pain management strategies safely and effectively d. Reports decreased pain and increased comfort level 2. Experiences reduction in level of fatigue a. Identifies factors that contribute to fatigue b. Verbalizes the relationship of fatigue to disease activity c. Schedules periodic rest periods and identifies and uses other measures to prevent or modify fatigue d. Reports decreased level of fatigue e. Practices energy conservation strategies 3. Improves sleep patterns a. Reports fewer night-time awakenings b. Adheres to sleep-inducing routine c. Reports feeling rested upon awakening 4. Increases or maintains level of mobility a. Identifies factors that impede mobility b. Participates in activities and exercises that promote or maintain mobility c. Uses assistive devices appropriately and safely d. Demonstrates normal or acceptable body alignment and posture 5. Maintains self-care activities a. Participates in self-care activities within capabilities b. Uses adaptive equipment and alternative methods to increase participation in self-care activities c. Maintains self-care at highest possible level 6. Experiences improved body image and coping a. Verbalizes concerns about the impact of rheumatic disease on appearance and function b. Sets and achieves meaningful goals c. States acceptance of self-worth d. Adapts to body image changes caused by disease e. Identifies and uses effective coping strategies 7. Experiences absence of complications a. Takes medications as prescribed b. States potential side effects of medications and names reportable side effects c. Verbalizes understanding of rationale for monitoring d. Complies with recommendations for monitoring e. Identifies strategies to reduce risks of side effects
Diffuse Connective Tissue Diseases Diffuse connective tissue disease refers to a group of disorders that are chronic in nature and characterized by diffuse inflammation and degeneration in the connective tissues. These disorders share similar clinical features and may affect some of the same organs. The characteristic clinical course is one of exacerbations and remissions. Although the diffuse connective tissue diseases have unknown causes, they are thought to be the result of immunologic abnormalities. They include RA, SLE, scleroderma, polymyositis, and polymyalgia rheumatica.
Chapter 54
Assessment and Management of Patients With Rheumatic Disorders
RHEUMATOID ARTHRITIS Pathophysiology RA is commonly used as the prototype for inflammatory arthritis. The incidence rate is approximately 3%, with a two to three times greater incidence in women (Ruddy et al., 2001). In RA, the autoimmune reaction (Fig. 54-3) primarily occurs in the synovial tissue. Phagocytosis produces enzymes within the joint. The enzymes break down collagen, causing edema, proliferation of the synovial membrane, and ultimately pannus formation. Pannus destroys cartilage and erodes the bone. The consequence is loss of articular surfaces and joint motion. Muscle fibers undergo degenerative changes. Tendon and ligament elasticity and contractile power are lost.
Clinical Manifestations Clinical manifestations of RA vary, usually reflecting the stage and severity of the disease. Joint pain, swelling, warmth, erythema, and lack of function are classic. Palpation of the joints reveals spongy or boggy tissue. Often fluid can be aspirated from
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the inflamed joint. Characteristically, the pattern of joint involvement begins with the small joints in the hands, wrists, and feet. As the disease progresses, the knees, shoulders, hips, elbows, ankles, cervical spine, and temporomandibular joints are involved. The onset of symptoms is usually acute. Symptoms are usually bilateral and symmetric. In addition to joint pain and swelling, another classic sign of RA is joint stiffness, especially in the morning, lasting for more than 30 minutes (Klippel, 2001). In the early stages of disease, even before bony changes occur, limitation in function can occur when there is active inflammation in the joints. Joints that are hot, swollen, and painful are not easily moved. The patient tends to guard or protect these joints through immobilization. Immobilization for extended periods can lead to contractures, creating soft tissue deformity. Deformities of the hands and feet are common in RA (Fig. 54-4). The deformity may be caused by misalignment resulting from swelling, progressive joint destruction, or the subluxation (partial dislocation) that occurs when a bone slips over another and eliminates the joint space. RA is a systemic disease with multiple extra-articular features. Most common are fever, weight loss, fatigue, anemia, lymph node enlargement, and Raynaud’s phenomenon (cold- and
Physiology/Pathophysiology
Presentation of antigen to T cells
FIGURE 54-3
Pathophysiology and associated physical signs of rheumatoid arthritis.
T- and B-cell proliferation. Angiogenesis in synovial lining.
Swelling in small joints, associated with pain, stiffness, and fatigue.
Neutrophil accumulation in synovial fluid. Cell proliferation. No cartilage invasion.
Warm, swollen, effusions, pain, and decreased motion with possible rheumatoid nodules.
Synovitis. Early pannus invasion. Chondrocyte activation. Degradation of cartilage by proteinase.
Increase in severity of physical signs and symptoms.
Subchondral bone erosion. Pannus invasion of cartilage. Chondrocyte proliferation. Laxity of ligaments.
Joint instability, contractures, decreased ROM, systemic complications.
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Unit 11
IMMUNOLOGIC FUNCTION
fluid that is cloudy, milky, or dark yellow and contains numerous inflammatory components, such as leukocytes and complement. X-ray studies, performed to help diagnose and monitor the progression of disease, show characteristic bony erosions and narrowed joint spaces occurring later in the disease.
Medical Management
A
B
FIGURE 54-4
Rheumatoid arthritis. (A) Early. (B) Advanced.
stress-induced vasospasm causing episodes of digital blanching or cyanosis). Rheumatoid nodules may be noted in patients with more advanced RA and develop at some time in up to half of patients (Klippel, 2001). These nodules are usually nontender and movable in the subcutaneous tissue. They usually appear over bony prominences such as the elbow, are varied in size, and can disappear spontaneously. Nodules occur only in individuals who have rheumatoid factor. The nodules often are associated with rapidly progressive and destructive disease. Other extra-articular features include arteritis, neuropathy, scleritis, pericarditis, splenomegaly, and Sjögren’s syndrome (dry eyes and dry mucous membranes).
Assessment and Diagnostic Findings Several factors can contribute to a diagnosis of RA: rheumatoid nodules, joint inflammation detected on palpation, and certain laboratory findings. The history and physical examination address manifestations such as bilateral and symmetric stiffness, tenderness, swelling, and temperature changes in the joints. The patient is also assessed for extra-articular changes; these often include weight loss, sensory changes, lymph node enlargement, and fatigue. Rheumatoid factor is present in more than 80% of patients with RA, but its presence alone is not diagnostic of RA. The erythrocyte sedimentation rate (ESR) is significantly elevated with RA. The red blood cell count and C4 complement component are decreased. C-reactive protein and antinuclear antibody test results may also be positive. Arthrocentesis shows synovial
EARLY-STAGE RA In patients with early RA, treatment begins with education, a balance of rest and exercise, and referral to community agencies for support. Medical management begins with therapeutic doses of salicylates or NSAIDs. When used in full therapeutic dosages, these medications provide both anti-inflammatory and analgesic effects. Taking medications as prescribed to maintain a consistent blood level is necessary to optimize the effectiveness of the antiinflammatory medication. Several COX-2 inhibitors, another class of NSAIDs, have been approved for treatment of RA. COX (cyclo-oxygenase) is an enzyme involved in the inflammatory process. COX-2 inhibitors block the enzyme involved in inflammation while leaving intact the enzyme involved in protecting the stomach lining. As a result, COX-2 inhibitors are less likely to cause gastric irritation and ulceration than other NSAIDs (Bombardier et al., 2000). The trend in management is toward a more aggressive pharmacologic approach earlier in the disease. A window of opportunity for symptom control and improved disease management occurs within the first 2 years of disease onset. Therefore, the diseasemodifying antirheumatic agents (antimalarials, gold, penicillamine, or sulfasalazine) are initiated early in treatment. If symptoms appear to be aggressive (ie, early bony erosions as seen on x-rays), methotrexate may be considered. Methotrexate is currently the gold standard in the treatment of RA because of its success in improving disease parameters (ie, pain, tender and swollen joints, quality of life). The goals are to control symptoms and prevent destruction of the joints (Koopman, 2001). An alternative treatment approach for RA has emerged in the area of biologic therapies. Biologic response modifiers are a group of agents that consist of molecules produced by cells of the immune system or by cells that participate in the inflammatory reactions (Koopman, 2001). Recent studies (Moreland et al., 1999; Weinblatt et al., 1999) using tumor necrosis factor-alpha inhibitors, both alone and in combination with other medications, have shown that patients demonstrate significant improvement based on American College of Rheumatology criteria (Felson et al., 1995). Two examples of biologic response modifiers that are currently available are enatercept (Enbrel) and infliximab (Remicade). These agents inhibit the function of tumor necrosis factor-alpha, a key cytokine known to play a role in the disease process in RA (Miller, 2001). Research in this area is ongoing. Additional analgesia may be prescribed for periods of extreme pain. Opioid analgesics are avoided because of the potential for continuing need for pain relief. Nonpharmacologic pain management techniques (eg, relaxation techniques, heat and cold applications) are taught. MODERATE, EROSIVE RA For moderate, erosive RA, a formal program with occupational and physical therapy is prescribed to educate the patient about principles of joint protection, pacing activities, work simplification, range of motion, and muscle-strengthening exercises. The patient is encouraged to participate actively in the management program. The medication program is reevaluated periodically, and appropriate changes are made if indicated. Cyclosporine,
Chapter 54
Assessment and Management of Patients With Rheumatic Disorders
an immunomodulator, may be added to enhance the diseasemodifying effect of methotrexate. PERSISTENT, EROSIVE RA For persistent, erosive RA, reconstructive surgery and corticosteroids are often used. Reconstructive surgery is indicated when pain cannot be relieved by conservative measures. Surgical procedures include synovectomy (excision of the synovial membrane), tenorrhaphy (suturing a tendon), arthrodesis (surgical fusion of the joint), and arthroplasty (surgical repair and replacement of the joint). Surgery is not performed during disease flares. Systemic corticosteroids are used when the patient has unremitting inflammation and pain or needs a “bridging” medication while waiting for the slower disease-modifying antirheumatic agent (eg, methotrexate) to begin working. Low-dose corticosteroid therapy is prescribed for the shortest time necessary to minimize side effects. Joints that are severely inflamed and fail to respond promptly to the measures outlined previously may be treated by local injection of a corticosteroid (Ruddy et al., 2001). ADVANCED, UNREMITTING RA For advanced, unremitting RA, immunosuppressive agents are prescribed because of their ability to affect the production of antibodies at the cellular level. These include high-dose methotrexate (Rheumatrex), cyclophosphamide (Cytoxan), and azathioprine (Imuran). These medications, however, are highly toxic and can produce bone marrow suppression, anemia, gastrointestinal disturbances, and rashes. Through all stages of RA, depression and sleep deprivation may require the short-term use of low-dose antidepressant medications, such as amitriptyline (Elavil), paroxetine (Paxil), or sertraline (Zoloft), to reestablish an adequate sleep pattern and to manage chronic pain better. The FDA has approved a medical device for use in treating patients with more severe and longstanding cases of RA who have failed to respond to or are intolerant of disease-modifying antirheumatic drugs. The device, a protein A Immunoadsorption column (Prosorba), is used in 12 weekly 2-hour apheresis treatments to bind IgG (ie, circulating immune complex). In this unique population of patients, a significant improvement using the American College of Rheumatology Criteria for Improvement has been demonstrated in several studies using the Prosorba column (Felson et al., 1999; Gendreau, 2001).
Nutrition Therapy Patients with RA frequently experience anorexia, weight loss, and anemia. A dietary history identifies usual eating habits and food preferences. Food selection should include the daily requirements from the basic food groups, with emphasis on foods high in vitamins, protein, and iron for tissue building and repair. For the extremely anorexic patient, small, frequent feedings with increased protein supplements may be prescribed. Some medications (ie, oral corticosteroids) used in RA treatment stimulate the appetite and, when combined with decreased activity, may lead to weight gain. Therefore, patients may need to be counseled about eating a healthy, calorie-restricted diet.
Nursing Management Nursing care of the patient with RA follows the basic plan of care presented earlier in the chapter. The most common issues for the patient with RA include pain, sleep disturbance, fatigue,
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altered mood, and limited mobility. The patient with newly diagnosed RA needs information about the disease to make daily selfmanagement decisions and to cope with having a chronic disease. Because of repeated contact with the patient, the nurse has the opportunity to assess and intervene in patient concerns and issues that occur with the diagnosis of a chronic illness such as RA. Because the disease commonly affects young women, major concerns may be related to the effects of the disease on childbearing potential, caring for family, or work responsibilities. The patient with a chronic illness may seek a “cure” or have questions about alternative therapies. Frequently, however, patients are hesitant to share their concerns with health care professionals (American College of Rheumatology, 1998).
SYSTEMIC LUPUS ERYTHEMATOSUS The overall prevalence of SLE is estimated to be 100 per 100,000 persons. It occurs 10 times more frequently in women than in men and approximately three times more frequently in the African-American population than in Caucasians (Ruddy et al., 2001).
Pathophysiology SLE is a result of disturbed immune regulation that causes an exaggerated production of autoantibodies. This immunoregulatory disturbance is brought about by some combination of genetic, hormonal (as evidenced by the usual onset during the childbearing years), and environmental factors (sunlight, thermal burns). Certain medications, such as hydralazine (Apresoline), procainamide (Pronestyl), isoniazid (INH), chlorpromazine (Thorazine), and some antiseizure medications, have been implicated in chemical or drug-induced SLE. In SLE, the increase in autoantibody production is thought to result from abnormal suppressor T-cell function, leading to immune complex deposition and tissue damage. Inflammation stimulates antigens, which in turn stimulate additional antibodies, and the cycle repeats.
Clinical Manifestations The onset of SLE may be insidious or acute. For this reason, SLE may remain undiagnosed for many years. Clinical features of SLE involve multiple body systems. SYSTEMIC MANIFESTATIONS SLE is an autoimmune systemic disease that can affect any body system. Involvement of the musculoskeletal system, with arthralgias and arthritis (synovitis), is a common presenting feature of SLE. Joint swelling, tenderness, and pain on movement are also common. Frequently, these are accompanied by morning stiffness. Several different types of skin manifestations may occur in patients with SLE, including subacute cutaneous lupus erythematosus, which involves papulosquamous or annular polycyclic lesions, and discoid lupus erythematosus, which is a chronic rash that has erythematous papules or plaques and scaling and can cause scarring and pigmentation changes. The most familiar skin manifestation (but occurring in fewer than half of patients with SLE) is an acute cutaneous lesion consisting of a butterfly-shaped rash across the bridge of the nose and cheeks (Fig. 54-5). In some cases of discoid lupus erythematosus, only skin involvement may occur. In some SLE patients, the initial skin involvement may be
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FIGURE 54-5
Unit 11
IMMUNOLOGIC FUNCTION
The characteristic butterfly rash of systemic lupus erythe-
matosus.
the precursor to more systemic involvement. The lesions often worsen during exacerbations (flares) of the systemic disease and possibly are provoked by sunlight or artificial ultraviolet light. Oral ulcers, which may accompany skin lesions, may involve the buccal mucosa or the hard palate. The ulcers occur in crops and are often associated with exacerbations. Pericarditis is the most common cardiac manifestation. Women who have SLE are also at risk for early atherosclerosis. Serum creatinine levels and urinalysis are used in screening for renal involvement. Early detection allows for prompt treatment so that renal damage can be prevented. Renal involvement may lead to hypertension, which also requires careful monitoring and management. Central nervous system involvement is widespread, encompassing the entire range of neurologic disease. The varied and frequent neuropsychiatric presentations of SLE are now widely recognized. These are generally demonstrated by subtle changes in behavior patterns or cognitive ability. Depression and psychosis are common (Klippel, 2001; Petri, 2000; Ruddy et al., 2001).
Assessment and Diagnostic Findings Diagnosis of SLE is based on a complete history, physical examination, and blood tests. In addition to the general assessment performed for any patient with a rheumatic disease, assessment for known or suspected SLE has special features. The skin is inspected for erythematous rashes. Cutaneous erythematous plaques with an adherent scale may be observed on the scalp, face, or neck. Areas of hyperpigmentation or depigmentation may be noted, depending on the phase and type of the disease. The patient should be questioned about skin changes (because these may be transitory) and specifically about sensitivity to sunlight or artificial ultraviolet light. The scalp should be inspected for alopecia and the mouth and throat for ulcerations reflecting gastrointestinal involvement.
Cardiovascular assessment includes auscultation for pericardial friction rub, possibly associated with myocarditis and accompanying pleural effusions. The pleural effusions and infiltrations, which reflect respiratory insufficiency, are demonstrated by abnormal lung sounds. Papular, erythematous, and purpuric lesions developing on the fingertips, elbows, toes, and extensor surfaces of the forearms or lateral sides of the hand that may become necrotic suggest vascular involvement. Joint swelling, tenderness, warmth, pain on movement, stiffness, and edema may be detected on physical examination. The joint involvement is often symmetric and similar to that found in RA. Typically, assessment reveals classic symptoms, including fever, fatigue, and weight loss and possibly arthritis, pleurisy, and pericarditis. Interactions with the patient and family may provide further evidence of systemic involvement. The neurologic assessment is directed at identifying and describing any central nervous system changes. The patient and family members are asked about any behavioral changes, including manifestations of neuroses or psychosis. Signs of depression are noted, as are reports of seizures, chorea, or other central nervous system manifestations. No single laboratory test confirms SLE; rather, blood testing reveals moderate to severe anemia, thrombocytopenia, leukocytosis, or leukopenia and positive antinuclear antibodies. Other diagnostic immunologic tests support but do not confirm the diagnosis. Hematuria may be found on urinalysis.
Medical Management Treatment of SLE includes management of acute and chronic disease. Although SLE can be life-threatening, advances in its treatment have led to improved survival and reduced morbidity. Acute disease requires interventions directed at controlling increased disease activity or exacerbations that may involve any organ system. Disease activity is a composite of clinical and laboratory features that reflect active inflammation secondary to SLE. Management of the more chronic condition involves periodic monitoring and recognition of meaningful clinical changes requiring adjustments in therapy (Ruddy et al., 2001). The goals of treatment include preventing progressive loss of organ function, reducing the likelihood of acute disease, minimizing disease-related disabilities, and preventing complications from therapy. Management of SLE involves regular monitoring to assess disease activity and therapeutic effectiveness. PHARMACOLOGIC THERAPY Medication therapy for SLE is based on the concept that local tissue inflammation is mediated by exaggerated or heightened immune responses, which can vary widely in intensity and require different therapies at different times. The NSAIDs used for minor clinical manifestations are often used along with corticosteroids in an effort to minimize corticosteroid requirements. Corticosteroids are the single most important medication available for treatment. They are used topically for cutaneous manifestations, in low oral doses for minor disease activity, and in high doses for major disease activity. Intravenous administration of corticosteroids is an alternative to traditional high-dose oral use. Antimalarial medications are effective for managing cutaneous, musculoskeletal, and mild systemic features of SLE. Immunosuppressive agents (alkylating agents and purine analogs) are used because of their effect on immune function. These medications are generally reserved for patients who have serious forms
Chapter 54
Assessment and Management of Patients With Rheumatic Disorders
of SLE and who have not responded to conservative therapies (Kimberly, 2001; National Institutes of Health, 1998; Ruddy et al., 2001).
Nursing Management The nursing care of the patient with SLE is based on the basic plan presented earlier in the chapter. The most common problems include fatigue, impaired skin integrity, body image disturbance, and lack of knowledge for self-management decisions. The disease or its treatment may produce dramatic changes in appearance and considerable distress for the patient. The changes and the unpredictable course of SLE necessitate expert assessment skills and nursing care and sensitivity to the psychological reactions of the patient. Patients may benefit from participation in support groups by receiving disease information, daily management tips, and social support. Because sun and ultraviolet light exposure can increase disease activity or cause an exacerbation, patients should be taught to avoid exposure or to protect themselves with sunscreen and clothing. Because of the increased risk for involvement of multiple organ systems, patients should understand the need for routine periodic screenings as well as health promotion activities. A dietary consultation may be indicated to ensure that the patient is knowledgeable about dietary recommendations, given the increased risk for cardiovascular disease, including hypertension and atherosclerosis. The nurse instructs the patient about the importance of continuing prescribed medications and addresses the changes and side effects that are likely with their use. The patient is reminded of the importance of monitoring because of the increased risk for systemic involvement, including renal and cardiovascular effects.
SCLERODERMA Scleroderma (“hard skin”) is a relatively rare disease that is poorly understood; the cause is unknown. Its incidence is 18 to 20 persons per million per year (Ruddy et al., 2001).
Pathophysiology Like other diffuse connective tissue diseases, scleroderma (also known as systemic sclerosis) has a variable course with remissions and exacerbations. Its prognosis is not as optimistic as that of SLE. The disease commonly begins with skin involvement. Mononuclear cells cluster on the skin and stimulate lymphokines to stimulate procollagen. Insoluble collagen is formed and accumulates excessively in the tissues. Initially, the inflammatory response causes edema formation, with a resulting taut, smooth, and shiny skin appearance. The skin then undergoes fibrotic changes, leading to loss of elasticity and movement. Eventually, the tissue degenerates and becomes nonfunctional. This chain of events, from inflammation to degeneration, also occurs in blood vessels, major organs, and body systems (Klippel, 2001).
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spreads slowly; for years, these changes may remain localized in the hands and the feet. The face appears masklike, immobile, and expressionless, and the mouth becomes rigid. The changes within the body, although not visible directly, are vastly more important than the visible changes. The left ventricle of the heart is involved, resulting in heart failure. The esophagus hardens, interfering with swallowing. The lungs become scarred, impeding respiration. Digestive disturbances occur because of hardening (sclerosing) of the intestinal mucosa. Progressive renal failure may occur. The patient may manifest a variety of symptoms referred to as the CREST syndrome. CREST stands for calcinosis (calcium deposits in the tissues), Raynaud’s phenomenon, esophageal hardening and dysfunctioning, sclerodactyly (scleroderma of the digits), and telangiectasis (capillary dilation that forms a vascular lesion).
Assessment and Diagnostic Findings Assessment focuses on the sclerotic changes in the skin, contractures in the fingers, and color changes or lesions in the fingertips. Assessment of systemic involvement requires a systems review with special attention to gastrointestinal, pulmonary, renal, and cardiac symptoms. Limitations in mobility and self-care activities should be assessed, along with the impact the disease has had (or will have) on body image. There is no one conclusive test to diagnose scleroderma. A skin biopsy is performed to identify cellular changes specific to scleroderma. Pulmonary studies show ventilation-perfusion abnormalities. Echocardiography identifies pericardial effusion (often present with cardiac involvement). Esophageal studies demonstrate decreased motility in 75% of patients with scleroderma. Blood tests may detect antinuclear antibodies, indicating a connective tissue disorder and possibly distinguishing the subgroup of scleroderma. A positive antinuclear antibody test result is common in patients with scleroderma.
Medical Management Treatment of scleroderma depends on the clinical manifestations. All patients require counseling, during which realistic individual goals may be determined. Support measures include strategies to decrease pain and limit disability. A moderate exercise program is encouraged to prevent joint contractures. Patients are advised to avoid extreme temperatures and to use lotion to minimize skin dryness. PHARMACOLOGIC THERAPY No medication regimen has proved effective in modifying the disease process in scleroderma, but various medications are used to treat organ system involvement. Calcium channel blockers and other antihypertensive agents may provide improvement in symptoms of Raynaud’s phenomenon. Anti-inflammatory medications can be used to control arthralgia, stiffness, and general musculoskeletal discomfort (Klippel, 2001; Ramsey-Goldman, 2001).
Clinical Manifestations
Nursing Management
Scleroderma starts insidiously with Raynaud’s phenomenon and swelling in the hands. The skin and the subcutaneous tissues become increasingly hard and rigid and cannot be pinched up from the underlying structures. Wrinkles and lines are obliterated. The skin is dry because sweat secretion over the involved region is suppressed. The extremities stiffen and lose mobility. The condition
The nursing care of the patient with scleroderma is based on the basic plan of nursing care presented earlier in the chapter. The most common nursing diagnoses of the patient with scleroderma include impaired skin integrity; self-care deficits; imbalanced nutrition, less than body requirements; and disturbed body image. The patient with advanced disease may also have problems with
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IMMUNOLOGIC FUNCTION
impaired gas exchange, decreased cardiac output, impaired swallowing, and constipation. Providing meticulous skin care and preventing the effects of Raynaud’s phenomenon are major nursing challenges. Patient teaching must include the importance of avoiding cold and protecting the fingers with mittens in cold weather and when shopping in the frozen-food section of the grocery store. Warm socks and properly fitting shoes are helpful in preventing ulcers. Careful, frequent inspection for early ulcers is important. Smoking cessation is critical.
fatigue, self-care deficit, and insufficient knowledge of selfmanagement techniques. Patients with polymyositis may have symptoms similar to those of other inflammatory diseases. However, proximal muscle weakness is characteristic, making activities such as combing hair, reaching overhead, and using stairs difficult. Therefore, use of assistive devices may be recommended and referral to occupational or physical therapy may be warranted.
POLYMYOSITIS
Pathophysiology
Polymyositis is one of a group of diseases termed idiopathic inflammatory myopathies. It is a rare condition with an incidence that is estimated to be from fewer than one to eight cases per million (Ruddy et al., 2001).
The underlying mechanism involved with polymyalgia rheumatica is unknown. This disease occurs predominately in Caucasians and often in first-degree relatives. An association with the genetic marker HLA-DR4 suggests a familial predisposition. Immunoglobulin deposits in the walls of inflamed temporal arteries also suggest an autoimmune process.
Pathophysiology Polymyositis is classified as autoimmune because autoantibodies are present. However, these antibodies do not cause damage to muscle cells, indicating only an indirect role in tissue damage. The pathogenesis is multifactorial, and a genetic predisposition is likely. Drug-induced disease is rare. Some evidence suggests a viral link.
Clinical Manifestations The onset varies from sudden onset with rapid progression to a very slow, insidious onset. Proximal muscle weakness is typically a first symptom. Muscle weakness is usually symmetric and diffuse. Dermatomyositis, a related condition, is most commonly identified by an erythematous smooth or scaly lesion found over the joint surface.
Assessment and Diagnostic Findings A complete history and physical examination help to exclude other muscle-related disorders. As with other diffuse connective tissue disorders, no one test confirms polymyositis. An electromyogram is performed to rule out degenerative muscle disease. A muscle biopsy may reveal inflammatory infiltrate in the tissue. Serum studies indicate increased muscle enzyme activity.
Medical Management Management involves high-dose corticosteroid therapy initially, followed by a gradual dosage reduction over several months as muscle enzyme activity decreases. Patients who do not respond to corticosteroids require the addition of an immunosuppressive agent. For patients who are unresponsive to corticosteroids and immunosuppressive medications, plasmapheresis, lymphapheresis, and total-body irradiation have been used. Skin rashes may respond to the antimalarial drug hydroxychloroquine. Physical therapy is initiated slowly with range-of-motion exercises to maintain joint mobility, followed by gradual strengthening exercises (Klippel, 2001).
Nursing Management Nursing care is based on the basic plan of nursing care presented earlier in the chapter. The most frequent nursing diagnoses for the patient with polymyositis include impaired physical mobility,
POLYMYALGIA RHEUMATICA
Clinical Manifestations Polymyalgia rheumatica is characterized by severe proximal muscle discomfort with mild joint swelling. Severe aching in the neck, shoulder, and pelvic muscles is common. Stiffness is noticeable most often in the morning and after periods of inactivity. Systemic features include low-grade fever, weight loss, malaise, anorexia, and depression. Because polymyalgia rheumatica generally occurs in people 50 years of age and older, it may be confused with, or disregarded as, an inevitable consequence of aging. Giant cell arteritis, sometimes associated with polymyalgia rheumatica, may cause headaches, changes in vision, and jaw claudication. These symptoms should be evaluated immediately because of the potential for a sudden and permanent loss of vision if untreated. Polymyalgia rheumatica and giant cell arteritis generally have a self-limited course, lasting several months to several years (Paget, 2001).
Assessment and Diagnostic Findings Polymyalgia rheumatica and giant cell arteritis are found almost exclusively in people over 50 years of age. Giant cell arteritis has a reported incidence of 18 cases per 100,000, and polymyalgia rheumatica has an annual incidence rate of 52 cases per 100,000 over age 50 (Loeslie, 2000; Ruddy et al., 2001). Assessment focuses on musculoskeletal tenderness, weakness, and decreased function. Careful attention should be directed toward assessing the head (for changes in vision, headaches, and jaw claudication). Often diagnosis is difficult because of the lack of specificity of tests. A markedly high ESR is a screening test but is not definitive. Diagnosis is more likely to be made by eliminating other potential diagnoses, but this is highly dependent on the skills and experience of the diagnostician. The dramatic and immediate response to treatment with corticosteroids is considered by some to be diagnostic.
Medical Management Polymyalgia rheumatica (without giant cell arteritis) is treated with moderate doses of corticosteroids. NSAIDs are sometimes used for mild disease. For patients with giant cell arteritis, rapid initiation of and strict adherence to a regimen of corticosteroids are essential to avoid the complication of blindness.
Chapter 54
Assessment and Management of Patients With Rheumatic Disorders
Nursing Management
Physiology/Pathophysiology
The nursing care of the patient with polymyalgia rheumatica is based on the basic plan of nursing care presented earlier in the chapter. The most common nursing diagnoses include pain and insufficient knowledge of the medication regimen. A management concern is that the patient will take the prescribed medication, frequently corticosteroids, until symptoms improve and then discontinue the medication. The decision to discontinue the medication should be based on clinical and laboratory findings. Nursing implications are related to helping the patient prevent and monitor side effects from medications (eg, infections, diabetes mellitus, gastrointestinal problems, and depression) and adjust to side effects that cannot be prevented (eg, increased appetite and altered body image).
!
Mechanical injury
Genetic and hormonal factors
Release of cytokines
The loss of bone mass with corticosteroid use increases the risk for osteoporosis in this already at-risk population. Interventions to promote bone health such as adequate dietary calcium and vitamin D, weight-bearing exercise, and smoking cessation, if indicated, should be emphasized (Buckley et al., 2001; Loeslie, 2000).
Stimulation, production, and release of proteolytic enzymes, metalloproteases, collagenase
Degenerative Joint Disease (Osteoarthritis)
Pathophysiology OA may be thought of as the end result of many factors combining in a generalized predisposition to the disease. OA affects the articular cartilage, subchondral bone (the bony plate that supports the articular cartilage), and synovium. A combination of cartilage degradation, bone stiffening, and reactive inflammation of the synovium occurs. The basic degenerative process in the joint exemplified in OA is presented in Figure 54-6. Understanding of OA has been greatly expanded beyond what previously was thought of as simply “wear and tear” related to aging. Risk factors for OA are summarized in Chart 54-3. Congenital and developmental disorders of the hip are well known for predisposing a person to OA of the hip. These include congenital subluxation–dislocation of the hip, acetabular dysplasia, Legg-Calvé-Perthes disease, and slipped capital femoral epiphysis.
Previous joint damage
Chondrocyte response
Other
NURSING ALERT The nurse must emphasize to the patient the need for continued adherence to the prescribed medication regimen to avoid complications of giant cell arteritis such as blindness.
OA, also known as degenerative joint disease or osteoarthrosis (even though inflammation may be present), is the most common and frequently disabling of the joint disorders. OA is both overdiagnosed and trivialized; it is frequently overtreated or undertreated. The functional impact of OA on quality of life, especially for elderly patients, is often ignored. OA has been classified as primary (idiopathic), with no prior event or disease related to the OA, and secondary, resulting from previous joint injury or inflammatory disease. The distinction between primary and secondary OA is not always clear. Increasing age directly relates to the degenerative process in the joint, as the ability of the articular cartilage to resist microfracture with repetitive low loads diminishes. OA often begins in the third decade of life and peaks between the fifth and sixth decades. By age 75 years, 85% of the population has either x-ray or clinical evidence of OA, but only 15% to 25% of these people experience significant symptoms (Ruddy et al., 2001).
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Resulting damage predisposes to more....
FIGURE 54-6
Pathophysiology of osteoarthritis.
Obesity is now a well-recognized risk factor for the development of OA (USDHHS, 2001). Being overweight or obese also increases the pain and discomfort associated with the disease (Altman et al., 2000; Coggon et al., 2001).
Clinical Manifestations The primary clinical manifestations of OA are pain, stiffness, and functional impairment. The pain is due to an inflamed synovium, stretching of the joint capsule or ligaments, irritation of nerve endings in the periosteum over osteophytes, trabecular microfracture, intraosseous hypertension, bursitis, tendinitis, and muscle spasm. Stiffness, which is most commonly experienced in the morning or after awakening, usually lasts less than 30 minutes
Chart 54-3
Risk Factors for Osteoarthritis • • • • • •
Increased age Obesity Previous joint damage Repetitive use (occupational or recreational) Anatomic deformity Genetic susceptibility
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and decreases with movement. Functional impairment is due to pain on movement and limited motion caused by structural changes in the joints. Although OA occurs most often in weight-bearing joints (hips, knees, cervical and lumbar spine), the proximal and distal finger joints are also often involved. Characteristic bony nodes may be present; on inspection and palpation, these are usually painless, unless inflammation is present.
Assessment and Diagnostic Findings Diagnosis of OA is complicated because only 30% to 50% of patients with changes seen on x-rays report symptoms. Physical assessment of the musculoskeletal system reveals tender and enlarged joints. Inflammation, when present, is not the destructive type seen in the connective tissue diseases such as RA. OA is characterized by a progressive loss of the joint cartilage, which appears on x-ray as a narrowing of joint space. In addition, reactive changes occur at the joint margins and on the subchondral bone in the form of osteophytes (or spurs) as the cartilage attempts to regenerate. Neither the presence of osteophytes nor joint space narrowing alone is specific for OA; however, when combined, these are sensitive and specific findings. In early or mild OA, there is only a weak correlation between joint pain and synovitis. Blood tests are not useful in the diagnosis of OA.
Medical Management Although no treatment halts the degenerative process, certain preventive measures can slow the progress if undertaken early enough. These include weight reduction, prevention of injuries, perinatal screening for congenital hip disease, and ergonomic modifications. Conservative treatment measures include the use of heat, weight reduction, joint rest and avoidance of joint overuse, orthotic devices to support inflamed joints (splints, braces), isometric and postural exercises, and aerobic exercise. Occupational and physical therapy can help the patient adopt self-management strategies. PHARMACOLOGIC THERAPY Pharmacologic management of OA is directed toward symptom management and pain control. Medications are used in conjunction with nonpharmacologic strategies, which are the mainstay of OA management (Altman et al., 2000). In most patients with OA, the initial analgesic therapy is acetaminophen. Some patients respond to the nonselective NSAIDs, and patients who are at increased risk for gastrointestinal complications, especially gastrointestinal bleeding, have been managed effectively with COX-2 inhibitors (Altman et al., 2000; Beehrle & Evans, 1999; Bombardier et al., 2000; Pasero & McCaffery, 2001; Ruddy et al., 2001). Selection of medication is based on the patient’s needs, the stage of disease, and the risk for side effects. Other medications that may be considered are the opioids and intra-articular corticosteroids. Topical analgesics such as capsaicin and methylsalicylate are also recommended (Altman et al., 2000; Ruddy et al., 2001). Newer therapeutic approaches include glucosamine and chondroitin, which are thought to improve tissue function and retard breakdown of cartilage (Altman et al., 2000; McAlindon et al., 2000). Viscosupplementation, the intra-articular injection of hyaluronic acid, is thought to improve cartilage function and retard degradation; it may also have some anti-inflammatory effects (Huskisson & Donnelly, 1999; Watterson & Esdaile, 2000; Wright et al., 2000). Glucosamine and chondroitin and visco-
supplementation, although approved by the FDA, are still undergoing intensive investigation for safety and efficacy (Brandt et al., 2000). SURGICAL MANAGEMENT In moderate to severe OA, when pain is severe or because of loss of function, surgical intervention may be used. Procedures most commonly used are osteotomy (to alter the force distribution in the joint) and arthroplasty. In arthroplasty, diseased joint components are replaced with artificial products (see Chap. 67). Other procedures include viscosupplementation (the reconstitution of synovial fluid viscosity). Hyaluronic acid (Hyalgan, Synvisc), a glycosaminoglycan that acts as a lubricant and shockabsorbing fluid in the joint, may be used in this procedure. Hyaluronic acid stimulates the production of synoviocytes, possibly providing better and more prolonged pain control. A series of three to five weekly intra-articular injections are given. Pain relief may last for 6 months (Kellick et al., 1998). Tidal irrigation (lavage) of the knee involves the introduction and then removal of a large volume of saline into the joint through cannulas. In some cases it provides pain relief for up to 6 months (Klippel, 2001; Lozada & Altman, 2001).
Nursing Management The nursing management of the patient with OA includes both pharmacologic and nonpharmacologic approaches. The nonpharmacologic interventions are used first and continued with the addition of pharmacologic agents. Pain management and optimizing functional ability are major goals of nursing intervention. Patients’ understanding of their disease process and symptom pattern is critical to a plan of care. Because patients with OA are older, they may have other health problems. Commonly they are overweight, and they may have a sedentary lifestyle. Weight loss and an increase in aerobic activity such as walking, with special attention to quadriceps strengthening, are important approaches to pain management (Altman et al., 2000; Bautch et al., 1997; Ettinger et al., 1997). A referral for physical therapy or to an exercise program for individuals with similar problems may be very helpful. Canes or other assistive devices for ambulation should be considered. Exercises such as walking should be begun in moderation and increased gradually. Patients should plan their daily exercise for a time when the pain is least severe or should plan to use an analgesic, if appropriate, before exercising. Adequate pain management is important for the success of an exercise program.
Spondyloarthropathies The spondyloarthropathies are another category of systemic inflammatory disorders of the skeleton. The spondyloarthropathies include ankylosing spondylitis, reactive arthritis (Reiter’s syndrome), and psoriatic arthritis. Spondyloarthritis is also associated with inflammatory bowel diseases such as regional enteritis (Crohn’s disease) and ulcerative colitis. These rheumatic diseases share several clinical features. The inflammation tends to occur peripherally at the sites of attachment— at tendons, joint capsules, and ligaments. Periosteal inflammation may be present. Many patients have arthritis of the sacroiliac joints. Onset tends to occur during young adulthood, with the disease affecting men more often than women. There is a strong tendency for these conditions to occur in families. Frequently, the HLA-B27 genetic marker is found.
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NURSING RESEARCH PROFILE 54-1
Older Women With Osteoarthritis Baird, C. L. (2000). Living with hurting and difficulty doing: Older women with osteoarthritis. Clinical Excellence for Nurse Practitioners, 4(4), 231–237.
Purpose Osteoarthritis (OA), the most common rheumatic disorder in older adults, presents a major challenge to individuals’ independence. A greater understanding of patient experiences is necessary to develop appropriate needs-based interventions to help patients maintain independence. The purpose of this study was to develop an understanding of how OA affects individuals’ lives and to provide data on which to base nursing interventions. Study Sample And Design A qualitative research design was used. After informed written consent was obtained from eligible participants, semistructured interviews were conducted. The interviews were recorded for transcription and analysis. Data analyzed included the transcriptions of the interviews and the investigator’s field notes of observations and impressions. The sample comprised 18 women, 65 to 92 years of age, who reported having OA and who participated in an Area Council on Aging Center or were referred by other study participants. Data were continuously compared throughout data gathering and analysis. A process of deconstructing and reconstructing the data into several levels of categories was carried out. Findings Subjects reported a continuous condition of “living with OA” and “living with hurting.” Hurting characterized the participants’ experience because of its chronicity and the participants’ persistent discomfort and pain. The hurting was reported as being prominent during activities such as walking, attending to personal care, and managing tasks for independent living. This finding resulted in a second category: “living with difficulty doing.” The state of “living with difficulty doing” was characterized by being unable to carry out activities because of pain, stiffness, and instability. Personal care and completing household tasks became difficult and often impossible to accomplish. Nursing Implications The findings of this study demonstrate the need for health care providers to understand the problems associated with living with OA and to assess the impact of OA on activities of daily living. Further, the findings emphasize the need to help patients with OA to obtain pain relief and to develop alternative strategies to deal with pain and to accomplish tasks important to them. These strategies include helping patients to learn how to pace themselves and to use nonpharmacologic modalities along with pharmacologic therapies for pain relief.
ANKYLOSING SPONDYLITIS Ankylosing spondylitis affects the cartilaginous joints of the spine and surrounding tissues. Occasionally, the large synovial joints, such as hips, knees, or shoulders, may be involved. Ankylosing spondylitis is usually diagnosed in the second or third decade of life. The disease is not usually as severe in females as in males, in whom the disease is more prevalent and likely to include significant systemic involvement. Back pain is the characteristic feature. As the disease progresses, ankylosis of the entire spine may occur, leading to respiratory compromise and complications.
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REACTIVE ARTHRITIS (REITER’S SYNDROME) This disease process is called reactive because the arthritis occurs following an infection. It affects young adult males and is characterized primarily by urethritis, arthritis, and conjunctivitis. Dermatitis and ulcerations of the mouth and penis may also be present. Low back pain is common.
PSORIATIC ARTHRITIS Psoriatic arthritis is characterized by synovitis, polyarthritis, and spondylitis. Both psoriasis and arthritis are common conditions, and one theory suggests that the overlap of the two conditions is a chance occurrence. However, epidemiologic data suggest that the prevalence of arthritis in patients with psoriasis is 7% to 42%, exceeding the rate in the general population. Similarly, the prevalence of psoriasis in persons with arthritis is 2.6% to 7.0%, compared with 0.1% to 2.8% in the general population, supporting the theory that these two processes occur together in a unique disease process (Ruddy et al., 2001).
Medical Management of Spondyloarthropathies Medical management of spondyloarthropathies focuses on treating pain and maintaining mobility by suppressing inflammation. For the patient with ankylosing spondylitis, good body positioning and posture are essential, so that if ankylosis (fixation) does occur, the patient is in the most functional position. Maintaining range of motion with a regular exercise and muscle-strengthening program is especially important. PHARMACOLOGIC THERAPY Salicylates, NSAIDs, and corticosteroids often produce marked improvement in back, skin, and joint symptoms. Methotrexate is also used to control psoriasis as well as joint inflammation. SURGICAL MANAGEMENT Surgical management may include total hip replacement (see Chap. 67).
Nursing Management of Spondyloarthropathies Major nursing interventions in the spondyloarthropathies are related to symptom management and maintaining optimal functioning. This population is unique in rheumatology, because patients are primarily young men. Their major concerns are often related to prognosis and job modification, especially among those who perform physical work.
Metabolic and Endocrine Diseases Associated With Rheumatic Disorders Metabolic and endocrine diseases may be associated with rheumatic disorders. These include biochemical abnormalities (amyloidosis and scurvy), endocrine diseases (diabetes mellitus and acromegaly), immunodeficiency diseases (HIV infection, AIDS), and other hereditary disorders (hypermobility syndromes). The most common conditions, however, are the crystal-induced
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arthropathies in which crystals, such as monosodium urate (gout) or calcium pyrophosphate (calcium pyrophosphate dihydrate disease [CPPD] or pseudogout), are deposited within joints and other tissues.
GOUT Gout is a heterogeneous group of conditions related to a genetic defect of purine metabolism resulting in hyperuricemia. Oversecretion of uric acid or a renal defect resulting in decreased excretion of uric acid, or a combination of both, occurs. The prevalence of gout is reported to be 1.6 to 13.6 per thousand. The incidence increases with age and body mass index. It occurs more commonly in males than females (Ruddy et al., 2001). In primary hyperuricemia, elevated serum urate levels or manifestations of urate deposition appear to be consequences of faulty uric acid metabolism. Primary hyperuricemia may be due to severe dieting or starvation, excessive intake of foods that are high in purines (shellfish, organ meats), or heredity. In secondary hyperuricemia, gout is a clinical feature secondary to any of a number of genetic or acquired processes, including conditions in which there is an increase in cell turnover (leukemia, multiple myeloma, some types of anemias, psoriasis) and an increase in cell breakdown. Altered renal tubular function, either as a major action or as an unintended side effect of certain pharmacologic agents (diuretics such as thiazides and furosemide), low-dose salicylates, and ethanol can contribute to uric acid underexcretion.
For hyperuricemic people who are going to develop gout, acute arthritis is the most common early clinical manifestation. The metatarsophalangeal joint of the big toe is the most commonly affected (75% of patients). The tarsal area, ankle, or knee may also be affected. Less commonly, the wrists, fingers, and elbows may be affected. The acute attack may be triggered by trauma, alcohol ingestion, dieting, medications, surgical stress, or illness. The abrupt onset often occurs at night, awakening the patient with severe pain, redness, swelling, and warmth of the affected joint. Early attacks tend to subside spontaneously over 3 to 10 days even without treatment. The attack is followed by a symptom-free period (the intercritical stage) until the next attack, which may not come for months or years. With time, however, attacks tend to occur more frequently, involve more joints, and last longer. Tophi are generally associated with more frequent and severe inflammatory episodes. Higher serum concentrations of uric acid are also associated with more extensive tophus formation. Tophi most commonly occur in the synovium, olecranon bursa, subchondral bone, infrapatellar and Achilles tendons, subcutaneous tissue on the extensor surface of the forearms, and overlying joints. They have also been found in the aortic walls, heart valves, nasal and ear cartilage, eyelids, cornea, and sclerae. Joint enlargement may cause a loss of joint motion. Uric acid deposits may cause renal stones and kidney damage.
Medical Management
Hyperuricemia (serum concentration greater than 7 mg/dL [0.4 fmol/L]) can but does not always cause monosodium urate crystal deposition. However, as uric acid levels rise, risk increases (Ruddy et al., 2001). Attacks of gout appear to be related to sudden increases or decreases of serum uric acid levels. When the urate crystals precipitate within a joint, an inflammatory response occurs and an attack of gout begins. With repeated attacks, accumulations of sodium urate crystals, called tophi, are deposited in peripheral areas of the body, such as the great toe, the hands, and the ear. Renal urate lithiasis (kidney stones) with chronic renal disease secondary to urate deposition may develop. The finding of urate crystals in the synovial fluid of asymptomatic joints suggests that factors other than crystals may be related to the inflammatory reaction. Recovered monosodium urate crystals are coated with immunoglobulins that are mainly immunoglobulin G (IgG). IgG enhances crystal phagocytosis, thereby demonstrating immunologic activity.
A definitive diagnosis of gouty arthritis is established by polarized light microscopy of the synovial fluid of the involved joint. Uric acid crystals are seen within the polymorphonuclear leukocytes within the fluid. Colchicine (oral or parenteral) or an NSAID such as indomethacin is used to relieve an acute attack of gout. Management of hyperuricemia, tophi, joint destruction, and renal disorders is usually initiated after the acute inflammatory process has subsided. Uricosuric agents, such as probenecid, correct hyperuricemia and dissolve deposited urate. Allopurinol is also effective, but its use is limited because of the risk for toxicity. When reduction of the serum urate level is indicated, the uricosuric agents are the medications of choice. When the patient has, or is at risk for, renal insufficiency or renal calculi (kidney stones), allopurinol is the medication of choice. Corticosteroids may be used in resistant cases. If the individual experiences several acute episodes or there is evidence of tophi formation, prophylactic treatment is considered. Specific treatment is based on serum uric acid level, 24-hour urinary uric acid excretion, and renal function (Table 54-5).
Clinical Manifestations
Nursing Management
Manifestations of the gout syndrome include acute gouty arthritis (recurrent attacks of severe articular and periarticular inflammation), tophi (crystalline deposits accumulating in articular tissue, osseous tissue, soft tissue, and cartilage), gouty nephropathy (renal impairment), and uric acid urinary calculi. Four stages of gout can be identified: asymptomatic hyperuricemia, acute gouty arthritis, intercritical gout, and chronic tophaceous gout. The subsequent development of gout is directly related to the duration and magnitude of the hyperuricemia. Therefore, the commitment to lifelong pharmacologic treatment of hyperuricemia is deferred until there is an initial attack of gout.
Historically, gouty arthritis was thought to be a condition of the royalty and the very rich, with the disease attributed to “high living.” This has not been shown to be entirely true. While severe dietary restriction is not necessary, patients should be encouraged to restrict consumption of foods high in purines, especially organ meats, and to limit alcohol intake. Maintenance of normal body weight should be encouraged. In an acute episode of gouty arthritis, pain management is essential. During the intercritical period, the patient feels well and may abandon preventive behaviors, which may result in an acute attack. Acute attacks are most effectively treated if therapy is begun early in the course.
Pathophysiology
Chapter 54
Table 54-5
Assessment and Management of Patients With Rheumatic Disorders
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• Medications Used to Treat Gout
MEDICATION
ACTIONS AND USE
NURSING IMPLICATIONS
colchicine
Lowers the deposition of uric acid and interferes with leukocytes and kinin formation, thus reducing inflammation; does not alter serum or urine levels of uric acid; used in acute and chronic management Uricosuric agent; inhibits renal reabsorption of urates and increases the urinary excretion of uric acid; prevents tophi formation Xanthine oxidase inhibitor; interrupts the breakdown of purines before uric acid is formed; inhibits xanthinoxidase because it blocks uric acid formation
Acute management: Administer when attack begins; dosage increased until pain relieved or diarrhea develops Chronic management: Prolonged use may decrease vitamin B12 absorption; causes GI upset in most patients Be alert for nausea, rash, and constipation.
probenecid (Benemid)
allopurinol (Zyloprim)
Fibromyalgia Fibromyalgia is a common syndrome that involves chronic fatigue, generalized muscle aching, and stiffness. Two percent of the U.S. population, primarily women of childbearing age, are affected by this syndrome (American College of Rheumatology Fact Sheet, 2000). Although criteria for the classification of fibromyalgia have been established (Wolfe & Skevington, 1990), controversy exists as to whether this diagnosis represents a unique syndrome. The cause is unknown and no pathologic characteristics have been identified that are specific for the condition. Treatment consists of attention to the specific symptoms reported by the patient. NSAIDs may be used to treat the diffuse muscle aching and stiffness. Tricyclic antidepressants are used to improve or restore normal sleep patterns, and individualized programs of exercise are used to decrease muscle weakness and discomfort and to improve the general deconditioning that occurs in these individuals (American College of Rheumatology Fact Sheet, 2000; Burckhardt, 2001b; Clark et al., 2001).
Nursing Management Typically, patients with fibromyalgia have endured their symptoms for a long period of time. They may feel as if their symptoms have not been taken seriously. Nurses need to pay special attention to supporting these individuals and providing encouragement as they begin their program of therapy. Patient support groups may be helpful. Careful listening to patients’ descriptions of their concerns and symptoms is essential to helping them make changes necessary to improve their quality of life (Anderson & Burckhardt, 1999).
Arthritis Associated With Infectious Organisms Arthritis, tenosynovitis, and bursitis can be associated with infectious organisms. Some inflammation of joints, tendons, and bursae is directly related to infection caused by bacterial, viral, fungal, or parasitic agents. Bacterial arthritis is the most rapidly destructive form of infectious arthritis. There are two major classes of bacterial arthritis: arthritis caused by Neisseria gonorrhoeae and nongonococcal bacterium. The most prevalent of the nongonococcal organisms include Staphylococcus aureus and the various
Monitor for side effects, including bone marrow depression, vomiting, and abdominal pain.
streptococcal variants. Less common pathogens are related to syphilis, tuberculosis, leprosy, fungi (particularly coccidioidomycosis), mycoplasmas, and viral agents, such as rubella, parvovirus, and hepatitis B.
Clinical Manifestations The characteristic symptom is acute onset of a warm, swollen joint. Culture of the bacterium from the synovial fluid confirms the diagnosis. The patient often immobilizes the joint and elevates the affected extremity because of pain and swelling. Fever may be high or it may be absent. Signs of systemic infection may be lacking in elderly patients, those with diabetes, and those with suppressed immune systems. Diagnosis and treatment may be delayed by patients with pre-existing arthritic conditions if they attribute the symptoms to a flare-up of arthritis.
Management This condition is a medical emergency necessitating early diagnosis and appropriate treatment to eliminate the causative organism; otherwise, the joint may be destroyed relatively quickly. Treatment consists of parenteral antibiotics and drainage of the joint. The results of cultures are used to determine the appropriate antibiotic therapy. Immobilization of the joint and repeated joint aspirations may be necessary along with intravenous antibiotics. Nursing management focuses on providing pain relief, administering antibiotics, and assisting the patient with self-care activities. If the patient is sent home on intravenous antibiotics, the nurse arranges home care and instructs the patient and care providers in safe administration and changes to report to a health care provider.
Neoplasms and Neurovascular, Bone, and Extra-Articular Disorders Primary neoplasms of joints, tendon sheaths, and bursae are rare. Most neoplasms are benign, arising from the synovium. These benign tumors include lipoma, hemangioma, and fibroma and tumor-like lesions such as ganglion, bursitis, and synovial cyst. Malignant tumors include primary tumors, such as synovial and bone sarcomas, and secondary involvement as manifestations of
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joint invasion by leukemia, lymphoma, and myeloma or metastasis. Neoplasms may present as back or neck pain. Neurovascular disorders include the compression syndromes, such as those with peripheral entrapment (carpal tunnel syndrome), radiculopathy, and spinal stenosis. Raynaud’s phenomenon or disease and erythromelalgia (throbbing and burning pain often affecting the hands and feet) are also included in this category. Bone and cartilage disorders include osteoporosis, osteomalacia, hypertrophic osteoarthropathy, diffuse idiopathic skeletal hyperostosis, Paget’s disease, osteonecrosis, avascular necrosis, costochondritis, osteolysis or chondrolysis, and biomechanical or anatomic abnormalities. Notably, these conditions involve resorption, destruction, infection, or remodeling of bone. Extra-articular rheumatism is a descriptive term for a group of conditions affecting structures other than the joints. Included are general and regional pain syndromes, low back pain and intervertebral disk disorders, tendonitis and bursitis, and ganglion cysts.
Miscellaneous Disorders The last category in the classification of the rheumatic diseases is aptly labeled miscellaneous disorders because it contains a mix of disorders frequently associated with arthritis and other conditions. These disorders include the direct result of trauma (including internal derangement and loose bodies of joints), pancreatic disease (related to avascular necrosis or osteonecrosis), sarcoidosis (a multisystem disorder particularly of the lymph nodes and lungs), and palindromic rheumatism (an uncommon variety of recurring and acute arthritis and periarthritis that in some may progress to RA but is characterized by symptom-free periods of days to months). Other conditions include villonodular synovitis, chronic active hepatitis, and drug-related rheumatic syndromes. The nursing interventions related to these varied conditions are specific to the multisystemic problems experienced by the patient. However, the musculoskeletal components should not be neglected or overlooked. Further information about these rare disorders can be found in specialty references.
?
Critical Thinking Exercises
1.
Your 28-year-old, newly married patient has recently been informed that she has SLE. Although she is undergoing extensive testing to determine the systemic effects of SLE, she states that she feels fine and cannot understand the reasons for the testing. What explanations would you provide? Explain the relationship of SLE to possible systemic effects of the disorder.
2.
A 68-year-old woman is admitted for surgery to treat a bowel obstruction; it is anticipated that she will have a colostomy. She has advanced rheumatoid arthritis that has affected all four extremities and her cervical spine. How will the rheumatoid arthritis affect her immediate postoperative care? What modifications are necessary to enable her to manage her colostomy, given the effects of arthritis on her hands?
3.
A 57-year-old patient with a long history of osteoarthritis comes to the emergency department with severe pain and swelling of his right knee of 10 days’ duration. His knee is
hot to the touch and he has a fever. He explains that he thought his symptoms were due to a flare-up of his osteoarthritis. It is suspected that he has infectious arthritis. Explain the possible consequences of this form of arthritis and the medical and nursing interventions you would anticipate. What are the possible consequences of the delay in seeking treatment?
4.
NSAIDs and corticosteroids have been prescribed for your patient’s rheumatic disorder. How do the actions of these medications differ, and what instructions and recommendations would you give to the patient to ensure their safe administration?
REFERENCES AND SELECTED READINGS Books Belza, B. (2001). Fatigue. In L. Robbins, C. S. Burckhardt, M. T. Hannan, & R. J. DeHoratius (Eds.), Clinical care in the rheumatic diseases (pp. 251–254). Atlanta: Association of Rheumatology Health Professionals. Burckhardt, C. (2001a). Pain management. In L. Robbins, C. S. Burckhardt, M. T. Hannan, & R. J. DeHoratius (Eds.), Clinical care in the rheumatic diseases (pp. 245–249). Atlanta: Association of Rheumatology Health Professionals. Burckhardt, C. S. (2001b). Fibromyalgia. In L. Robbins, C. S. Burckhardt, M. T. Hannan, & R. J. DeHoratius (Eds.), Clinical care in the rheumatic diseases (pp. 135–139). Atlanta: Association of Rheumatology Health Professionals. Klippel, J. H. (Ed.) (2001). Primer on the rheumatic diseases (12th ed.). Atlanta: Arthritis Foundation. Lozada, C. J., & Altman, R. D. (2001). Osteoarthritis. In L. Robbins, C. S. Burckhardt, M. T. Hannan, & R. J. DeHoratius (Eds.), Clinical care in the rheumatic diseases (pp. 97–103). Atlanta: Association of Rheumatology Health Professionals. Luck, J. N. (2001). Enhancing functional ability. In L. Robbins, C. S. Burckhardt, M. T. Hannan, & R. J. DeHoratius (Eds.), Clinical care in the rheumatic diseases (pp. 197–202). Atlanta: Association of Rheumatology Health Professionals Michocki, R. J. (2001). Polypharmacy and principles of drug therapy. In A. M. Adelman & M. P. Daly (Eds.), 20 common problems in geriatrics. New York: McGraw-Hill. Miller, D. R. (2001). Pharmacologic interventions in the 21st century. In L. Robbins, C. S. Burckhardt, M. T. Hannan, & R. J. DeHoratius (Eds.), Clinical care in the rheumatic diseases (pp. 169–177). Atlanta: Association of Rheumatology Health Professionals. Minor, M. A., & Westby, M. D. (2001). Rest and exercise. In L. Robbins, C. S. Burckhardt, M. T. Hannan, & R. J. DeHoratius (Eds.). Clinical care in the rheumatic diseases (pp. 179–184). Atlanta: Association of Rheumatology Health Professionals. Nadler, S. (1997). Arthritis and other connective tissue diseases. In M. L. Sipski & C. J. Alexander (Eds.), Sexual function in people with disability and chronic illness. Gaithersburg, MD: Aspen. Paget, S. A. (2001). Polymyalgia rheumatica. In L. Robbins, C. S. Burckhardt, M. T. Hannan, & R. J. DeHoratius (Eds.), Clinical care in the rheumatic diseases (pp. 151–153). Atlanta: Association of Rheumatology Health Professionals. Parker, J. C., Wright, G. E., & Smarr, K. L. (2001). Psychological assessment. In L. Robbins, C. S. Burckhardt, M. T. Hannan, & R. J. DeHoratius (Eds.), Clinical care in the rheumatic diseases (pp. 69–73). Atlanta: Association of Rheumatology Health Professionals. Ramsey-Goldman, R. (2001). Connective tissue diseases. In L. Robbins, C. S. Burckhardt, M. T. Hannan, & R. J. DeHoratius (Eds.), Clinical care in the rheumatic diseases (pp. 97–103). Atlanta: Association of Rheumatology Health Professionals. Ruddy, S., Harris, E. D., & Sledge, C. B. (Eds.) (2001). Kelley’s textbook of rheumatology. Philadelphia: W. B. Saunders.
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U.S. Department of Health and Human Services. (2001). The Surgeon General’s call to action to prevent and decrease overweight and obesity. Rockville, MD: U.S. Department of Health and Human Services, Public Health Service. Wegner, S. T. (2001). Sleep problems. In L. Robbins, C. S. Burckhardt, M. T. Hannan, & R. J. DeHoratius (Eds.), Clinical care in the rheumatic diseases (pp. 255–259). Atlanta: Association of Rheumatology Health Professionals.
Journals Asterisks indicate nursing research articles. General American College of Rheumatology. (1998). Position statement: “Complementary” and “alternative” therapies for rheumatic diseases: http://www.rheumatology.org/position/alternative.html. *Aaronson, L. S., Teel, C. S., Cassmeyer, V., et al. (1999). Defining and measuring fatigue. Image: Journal of Nursing Scholarship, 31(1), 45–50. *Anderson, K. L., & Burckhardt, C. S. (1999). Conceptualization and measurement of quality of life as an outcome variable for health care intervention and research. Journal of Advanced Nursing, 29(2), 298–306. Beehrle, D. M., & Evans, D. (1999). A review of NSAID complications: Gastrointestinal and more. Lippincott’s Primary Care Practice, 3(3), 305–315. Bello, C. E., & Garrett, S. D. (1999). Therapeutic issues in oral glucocorticoid use. Lippincott’s Primary Care Practice, 3(3), 333–341. *Belza, B., Topolski, T., Kinne S., et al. (2002). Does adherence make a difference? Results from a community-based aquatic exercise program. Nursing Research, 51(5), 285–291. Buckley, L., Greenwald, M., Hochberg, M., et al. (2001). Recommendations for the prevention and treatment of glucocorticoid-induced osteoporosis. Arthritis & Rheumatism, 44(7), 1496–1503. Capriotti, T. (2000). The new NSAIDs: COX-2 inhibitors. MedSurg Nursing, 9(6), 313–317. Davidson, A., & Diamond, B. (2002). Advances in immunology. Autoimmune diseases. New England Journal of Medicine, 345(5), 340–350. *Jakobsson, U., & Hallberg, I. R. (2002). Pain and quality of life among older people with rheumatoid arthritis and/or osteoarthritis: A literature review. Journal of Clinical Nursing, 11(4), 430–443. Rheumatoid Arthritis *Ailinger, R. L., & Dear, M. R. (1997). An examination of the self-care needs of clients with rheumatoid arthritis. Rehabilitation Nursing, 22(3), 135–140. *Allaire, S. H., Anderson, J. J., & Meenan, R. F. (1996). Reducing work disability associated with rheumatoid arthritis: Identification of additional risk factors and persons likely to benefit from intervention. Arthritis Care Research, 9(5), 349–357. Bombardier, C., Laine, L., Reicin, A., et al. (2000). Comparison of upper gastrointestinal toxicity of Rofecoxib and Naproxen in patients with rheumatoid arthritis. New England Journal of Medicine, 343(21), 1520–1528. Felson, D. T., LaValley, M. P., Baldassare, A. R., et al. (1999). The Prosorba column for treatment of refractory rheumatoid arthritis: a randomized, double-blind, sham-controlled trial. Arthritis & Rheumatism, 42(10), 2153–2159. Felson, D. T., Anderson, J. J., Boers, M., et al. (1995). American College of Rheumatology preliminary definition of improvement in rheumatoid arthritis. Arthritis & Rheumatism, 38(6), 727–735. Gendreau, R. M. (2001). A randomized double-blind sham-controlled trial of the Prosorba column for treatment of refractory rheumatoid arthritis. Therapeutic Apheresis, 5(2), 79–83. Kellick, K. A., Martins-Richards, J., & Chow, C. (1998). Management of arthritis. Lippincott’s Primary Care Practice, 2(1), 66–80. Koopman, W. J. (2001). Prospects for autoimmune disease: Research advances in rheumatoid arthritis. Journal of the American Medical Association, 285(5), 648–650.
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MacLean, C. H., Rachel, L., et al. (2000). Quality of care for patients with rheumatoid arthritis. Journal of the American Medical Association, 284(8), 984–992. Moreland, L. W., Schiff, M. H., Baumgartner, S. W., et al. (1999). Etanercept therapy in rheumatoid arthritis. Annals of Internal Medicine, 130(6), 476–486. Multon, K. D., Parker, J. C., Smarr, K. L., et al. (2001). Effects of stress management on pain behavior in rheumatoid arthritis. Arthritis Care & Research, 45(2), 122–128. Ramsburg, K. K. (2000). Rheumatoid arthritis. American Journal of Nursing, 100(11), 40–43. Weinblatt, M. E., Kremer, J. M, Bankhurst, A. D., et al. (1999). A trial of etanercept, a recombinant tumor necrosis factor receptor: Fc fusion protein, in patients with rheumatoid arthritis receiving methotrexate. New England Journal of Medicine, 340(4), 253–259. Osteoarthritis Altman, R., Asch, E., Bloch, et al. (1986). Development of criteria for the classification and reporting of osteoarthritis: Classification of osteoarthritis of the knee. Arthritis & Rheumatism, 29(8), 1039–1049. Altman, R. D., Hochberg, M. C., Moskowitz, R. W., & Schnitzer, T. J. (2000). Recommendations for the medical management of osteoarthritis of the hip and knee. Arthritis & Rheumatism, 43(9), 1905–1915. American College of Rheumatology. (2000). Recommendations for the medical management of osteoarthritis of the hip and knee. Arthritis & Rheumatism, 43(9), 1905–1915. *Baird, C. L. (2000). Living with hurting and difficulty doing: Older women with osteoarthritis. Clinical Excellence for Nurse Practitioners, 4(4), 231–237. *Bautch, J. C., Malone, D. G., & Vailas, A. C. (1997). Effects of exercise on knee joints with osteoarthritis: A pilot study of biologic markers. Arthritis Care Research, 10(1), 48–55. Brandt, K. D., Smith, G. N., Jr, & Simon, L. S. (2000). Intraarticular injection of hyaluronan as treatment for knee osteoarthritis: What is the evidence? Arthritis & Rheumatism, 43(6), 1192–1203. Coggon, D., Reading, I., Croft, P., et al. (2001). Knee osteoarthritis and obesity. International Journal of Obesity and Related Metabolic Disorders, (5), 622–627. *Davis, G. C., Hiemenz, M. L., & White, T. L. (2002). Barriers to managing chronic pain of older adults with arthritis. Journal of Nursing Scholarship, 34(2), 121–126. Ettinger, W. H., Burns, R., et al. (1997). A randomized trial comparing aerobic exercise and resistance exercise with a health education program in older adults with knee osteoarthritis: The Fitness Arthritis and Seniors Trial (FAST). Journal of the American Medical Association, 277(1), 25–31. *Gaines, J. M., Talbot, L. A., & Metter, E. J. (2002). The relationship of arthritis self-efficacy to functional performance in older men and women with osteoarthritis of the knee. Geriatric Nursing, 23(3), 167–170. Gonzalez-Gay, M. A., Garcia-Porrua, C., Salvarani, C., & Hunder, G. G. (1999). Diagnostic approach in a patient presenting with polymyalgia. Clinical and Experimental Rheumatology, 17(3), 276–278. Huskisson, E. C., & Donnelly, S. (1999). Hyaluronic acid in the treatment of osteoarthritis of the knee. Rheumatology, 38(7), 602–607. McAlindon, T. E., LaValley, M. P., Gulin, J. P., & Felson, D. T. (2000). Glucosamine and chondroitin for treatment of osteoarthritis. Journal of the American Medical Association, 283(11), 1469–1475. Pasero, C., & McCaffery, M. (2001). Selective COX-2 inhibitors. American Journal of Nursing, 101(4), 55–56. Watterson, J. R., & Esdaile, J. M. (2000). Viscosupplementation: Therapeutic mechanisms and clinical potential in osteoarthritis of the knee. Journal of the American Academy of Orthopedic Surgery, 8(5), 277–284. Wright, K. E., Maurer, S. G., & DiCesare, P. E. (2000). Viscosupplementation for osteoarthritis. American Journal of Orthopedics, 29(2), 80–89.
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IMMUNOLOGIC FUNCTION
Systemic Lupus Erythematosus Johnson, B. (1999). Systemic lupus erythematosus. American Journal of Nursing, 99(1), 40–41. National Institutes of Health, National Institute of Arthritis and Musculoskeletal and Skin Diseases. Handout on Health–Systemic Lupus Erythematosus, 1998. Kimberly, R. P. (2001). Research advances in systemic lupus erythematosus. Journal of the American Medical Association, 285(5), 650–652. Petri, M. (2000). Systemic lupus erythematosus: Women’s health issues. Bulletin on the Rheumatic Diseases, 49(8), 1–3. Wolfe, F., & Skevington, S. M. (2000). Measuring the epidemiology of distress: The rheumatology distress index. Journal of Rheumatology, 27(8), 2000–2009. Other Specific Rheumatic Diseases ACR Fact Sheet. (2002). Fibromyalgia. http://www.rheumatology.org/ patients/factsheet/fibromya.html. Clark, S. R., Jones, K. D., Burckhardt, C. S., & Bennett, R. (2001). Exercise for patients with fibromyalgia: Risks versus benefits. Current Rheumatology Reports, 3(2), 135–140. Khan, M. A. (2002). Update on spondyloarthropathies. Annals of Internal Medicine, 136(12), 896–907. Loeslie, V. (2000). Pain in the elderly: Polymyalgia rheumatica. Clinical Excellence for Nurse Practitioners, 4(6), 345–348. Wolfe, F., Smythe, H. A., Yunus, M. B., et al. (1990). The American College of Rheumatology 1990 criteria for the classification of
fibromyalgia: report of the multicenter criteria committee. Arthritis & Rheumatism, 33, 160–172.
RESOURCES AND WEBSITES American Fibromyalgia Syndrome Association, Inc., 6380 E. Tanque Verde, Suite D, Tucson, AZ 85615; (520) 733-1570; http://www. afsafund.org. American College of Rheumatology and Association of Rheumatology Health Professionals, 1800 Century Place, Suite 250, Atlanta, GA 30345; (404) 633-3777; http://www.rheumatology.org. Arthritis Foundation, P.O Box 7669, Atlanta, GA 30309; (404) 8727100 or (800) 283-7800 (information line); http://www.arthritis.org. Lupus Foundation of America, Inc., 1300 Picard Drive, Suite 200, Rockville, MD 20850-4303; (800) 558-0121; http://www.lupus. org/lupus. National Institute of Arthritis and Musculoskeletal and Skin Diseases, National Institutes of Health, Building 31, MSC 2350, 31 Center Drive, Bethesda, MD 20892-2350; (301) 496-8188, http://www. nih.gov/niams. Sjögren’s Syndrome Foundation, Inc., 333 N. Broadway, Jericho, NY 11753; (516) 933-6365; http://www.sjogrens.com. Spondylitis Association of America, 14827 Ventura Blvd. #222, Sherman Oaks, CA 91403; (800) 777-8189; e-mail:
[email protected] United Scleroderma Foundation, Inc., P.O. Box 399, Watsonville, CA 95077; (408) 728-2202; http://www.scleroderma.com.
Chapter
55 ●
Assessment of Integumentary Function
LEARNING OBJECTIVES
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On completion of this chapter, the learner will be able to: 1. Identify the structures and functions of the skin. 2. Differentiate the composition and function of each skin layer: 3. 4. 5. 6. 7. 8.
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epidermis, dermis, and subcutaneous tissue. Identify and describe primary and secondary skin lesions and their pattern and distribution. Recognize common skin eruptions and manifestations associated with systemic disease. Describe the normal aging process of the skin and skin changes common to elderly patients. List appropriate questions that will help elicit information during an assessment of the skin. Describe the components of physical assessment most useful when examining the skin, hair, and nails. Discuss common skin tests and procedures used in diagnosing skin and related disorders.
Chapter 55
S
kin disorders are encountered frequently in nursing practice. Skin-related disorders account for up to 10% of all ambulatory patient visits in this country. Because the skin mirrors the general condition of the patient, many systemic conditions may be accompanied by dermatologic manifestations (Fleischer et al., 2000). The psychological stress of illness or various personal and family problems is commonly exhibited outwardly as dermatologic problems. Any hospitalized patient may suddenly develop itching and a rash from the treatment regimen. In certain systemic conditions, such as hepatitis and some cancers, dermatologic manifestations may be the first sign of the disorder.
Anatomic and Physiologic Overview The largest organ system of the body, the skin is indispensable for human life. Skin forms a barrier between the internal organs and the external environment and participates in many vital body functions. The skin is contiguous with the mucous membrane at the external openings of the digestive, respiratory, and urogenital systems. Because skin disorders are readily visible, dermatologic complaints are commonly the primary reason for a patient to seek health care.
ANATOMY OF THE SKIN, HAIR, NAILS, AND GLANDS OF THE SKIN The skin is composed of three layers: epidermis, dermis, and subcutaneous tissue (Fig. 55-1). The epidermis is an outermost layer of stratified epithelial cells and composed predominantly of keratinocytes. It ranges in thickness from about 0.1 mm on the eyelids to about 1 mm on the palms of the hands and soles of the feet. Four distinct layers compose the epidermis, from innermost to outermost: stratum germinativum, stratum granulosum, stratum lucidum, and stratum corneum. Each layer becomes more differentiated (ie, mature and with more specific functions) as it rises from the basal stratum germinativum layer to the outermost stratum corneum layer.
Epidermis The epidermis, which is contiguous with the mucous membranes and the lining of the ear canals, consists of live, continuously dividing cells covered on the surface by dead cells that were origi-
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nally deeper in the dermis but were pushed upward by the newly developing, more differentiated cells underneath. This external layer is almost completely replaced every 3 to 4 weeks. The dead cells contain large amounts of keratin, an insoluble, fibrous protein that forms the outer barrier of the skin and has the capacity to repel pathogens and prevent excessive fluid loss from the body. Keratin is the principal hardening ingredient of the hair and nails. Melanocytes are the special cells of the epidermis that are primarily involved in producing the pigment melanin, which colors the skin and hair. The more melanin in the tissue, the darker is the color. Most of the skin of dark-skinned people and the darker areas of the skin on light-skinned people (eg, the nipple) contain larger amounts of this pigment. Normal skin color depends on race and varies from pale; almost ivory, to deep brown, almost pure black. Systemic disease affects skin color as well. For example, the skin appears bluish when there is insufficient oxygenation of the blood, yellow-green in people with jaundice, or red or flushed when there is inflammation or fever (Table 55-1). Production of melanin is controlled by a hormone secreted from the hypothalamus of the brain called melanocyte-stimulating hormone. It is believed that melanin can absorb ultraviolet light in sunlight. Two other cells are common to the epidermis: Merkel and Langerhans cells. Merkel cells are receptors that transmit stimuli to the axon through a chemical synapse. Langerhans cells are believed to play a significant role in cutaneous immune system reactions. These accessory cells of the afferent immune system process invading antigens and transport the antigens to the lymph system to activate the T lymphocytes. The epidermis is modified in different areas of the body. It is thickest over the palms of the hands and soles of the feet and contains increased amounts of keratin. The thickness of the epidermis can increase with use and can result in calluses forming on the hands or corns forming on the feet. The junction of the epidermis and dermis is an area of many undulations and furrows called rete ridges. This junction anchors the epidermis to the dermis and permits the free exchange of essential nutrients between the two layers. This interlocking between the dermis and epidermis produces ripples on the surface of the skin. On the fingertips, these ripples are called fingerprints. They are a person’s most individual characteristic, and they rarely change.
Glossary alopecia: loss of hair from any cause anagen phase: active phase of hair growth dermatosis: any abnormal skin condition erythema: redness of the skin caused by congestion of the capillaries hirsutism: the condition of having excessive hair growth hyperpigmentation: increase in the melanin of the skin, resulting in an increase in pigmentation hypopigmentation: decrease in the melanin of the skin, resulting in a loss of pigmentation keratin: an insoluble, fibrous protein that forms the outer layer of skin lichenification: leathery thickening of the skin
Merkel cells: cells of the epidermis that play a role in transmission of sensory messages melanin: the substance responsible for coloration of the skin melanocytes: cells of the skin that produce melanin petechiae: pinpoint red spots that appear on the skin as a result of blood leakage into the skin rete ridges: undulations and furrows that appear at the dermis–epidermis junction and are responsible for cementing together the two layers sebaceous glands: glands that exist within the epidermis and secrete sebum to keep the skin soft and pliable
sebum: fatty secretion of the sebaceous glands striae: bandlike streaks on the skin, distinguished by color, texture, depression, or elevation from the tissue in which they are found; usually purplish or white telangiectases: red marks on the skin caused by distention of the superficial blood vessels vitiligo: a localized or widespread condition characterized by destruction of the melanocytes in circumscribed areas of the skin, resulting in white patches Wood’s light: a blue light used for diagnosing skin conditions
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INTEGUMENTARY FUNCTION
Hair shaft Duct of sweat gland
Epidermis
Dermis
Horny layer Cellular layer Sebaceous gland Muscle that erects hair shaft Sweat gland Hair follicle Vein
FIGURE 55-1
Anatomic structures of the skin. From Bickley, L. S., & Hoekelman, R. A. (2003). Bates’ guide to physical examination and history taking, 8th ed. Philadelphia: Lippincott Williams & Wilkins.
Subcutaneous tissue
Dermis The dermis makes up the largest portion of the skin, providing strength and structure. It is composed of two layers: papillary and reticular. The papillary dermis lies directly beneath the epidermis and is composed primarily of fibroblast cells capable of producing one form of collagen, a component of connective tissue. The reticular layer lies beneath the papillary layer and also produces collagen and elastic bundles. The dermis is also made up of blood and lymph vessels, nerves, sweat and sebaceous glands, and hair roots. The dermis is often referred to as the “true skin.”
Subcutaneous Tissue The subcutaneous tissue, or hypodermis, is the innermost layer of the skin. It is primarily adipose tissue, which provides a cushion between the skin layers, muscles, and bones. It promotes skin mobility, molds body contours, and insulates the body. Fat is deposited and distributed according to the person’s gender and in part accounts for the difference in body shape between men and women. Overeating results in increased deposition of fat beneath the skin. The subcutaneous tissues and amount of fat deposited are important factors in body temperature regulation.
Hair An outgrowth of the skin, hair is present over the entire body except for the palms and soles. The hair consists of a root formed in the dermis and a hair shaft that projects beyond the skin. It grows in a cavity called a hair follicle. Proliferation of cells in the bulb of the hair causes the hair to form (see Fig. 55-1). Hair follicles undergo cycles of growth and rest. The rate of growth varies; beard growth is the most rapid, followed by hair on the scalp, axillae, thighs, and eyebrows. The growth or anagen phase may last up to 6 years for scalp hair, whereas the telogen or resting phase lasts for approximately 4 months. During telogen, hair sheds from the body. The hair follicle recycles into the growing phase spontaneously, or it can be induced by plucking out hairs. Growing and resting hair can be found side by side on all parts of the body. About 90% of the 100,000 hair follicles on a
Nerve Artery
normal scalp are in the growing phase at any one time, and 50 to 100 scalp hairs are shed each day. There is a small bulge on the side of the hair follicle that houses the stem cells that migrate down to the follicle root and begin the cycle of reproducing the hair shaft. It was discovered that these bulges also contain the stem cells that migrate upward to reproduce skin (Jaworski & Gilliam, 1999). The location of these cells on the side of the hair shaft rather than at the base is a factor in hair loss. In conditions in which inflammation causes damage to the root of the hair, regrowth is possible. However, if inflammation causes damage to the bulge on the side, stem cells are destroyed and hair does not grow. In certain locations on the body, hair growth is controlled by sex hormones. The most vivid example is the growth of hair on the face (ie, beard and mustache), chest, and back, which is controlled by the male hormones known as androgens. Some women with higher levels of testosterone have hair in the areas generally thought of as masculine, such as the face, chest, and lower abdomen. This is often a normal genetic variation; if it appears along with irregular menses and weight changes it may indicate a hormonal imbalance. Hair in different parts of the body serves different functions. The hairs of the eyes (ie, eyebrows and lashes), nose, and ears filter out dust, bugs, and airborne debris. The hair of the skin provides thermal insulation in lower animals. This function is enhanced during cold or fright by piloerection (ie, hairs standing on end), caused by contraction of the tiny erector muscles attached to the hair follicle. The piloerector response that occurs in humans is probably vestigial (ie, rudimentary). Hair color is supplied by various amounts of melanin within the hair shaft. Gray or white hair reflects the loss of pigment. Hair quantity and distribution can be affected by endocrine conditions. For example, Cushing’s syndrome causes hirsutism (ie, excessive hair growth, especially in women), and hypothyroidism (ie, underactive thyroid) causes changes in hair texture. In many cases, chemotherapy and radiation therapy cause hair thinning or weakening of the hair shaft, resulting in partial or complete alopecia (ie, hair loss) from the scalp and other parts of the body.
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Nails On the dorsal surface of the fingers and toes, a hard, transparent plate of keratin, called the nail, overlies the skin. The nail grows from its root, which lies under a thin fold of skin called the cuticle. The nail protects the fingers and toes by preserving their highly developed sensory functions, such as for picking up small objects. Nail growth is continuous throughout life, with an average growth of 0.1 mm daily. Growth is faster in fingernails than toenails and tends to slow with aging. Complete renewal of a fingernail takes about 170 days, whereas toenail renewal takes 12 to 18 months.
Glands of the Skin There are two types of skin glands: sebaceous glands and sweat glands (see Fig. 55-1). The sebaceous glands are associated with hair follicles. The ducts of the sebaceous glands empty sebum (ie, oily secretion) onto the space between the hair follicle and the hair shaft. For each hair there is a sebaceous gland, the secretions of which lubricate the hair and render the skin soft and pliable. Sweat glands are found in the skin over most of the body surface. They are heavily concentrated in the palms of the hands and soles of the feet. Only the glans penis, the margins of the lips, the external ear, and the nail bed are devoid of sweat glands. Sweat glands are subclassified into two categories: eccrine and apocrine. The eccrine sweat glands are found in all areas of the skin. Their ducts open directly onto the skin surface. The thin, watery secretion called sweat is produced in the basal coiled portion of the eccrine gland and is released into its narrow duct. Sweat is composed of predominantly water and contains about one half of the salt content of the blood plasma. Sweat is released from eccrine glands in response to elevated ambient temperature and elevated body temperature. The rate of sweat secretion is under the control of the sympathetic nervous system. Excessive sweating of the palms and soles, axillae, forehead, and other areas may occur in response to pain and stress. The apocrine sweat glands are larger, and unlike eccrine glands, their secretion contains parts of the secretory cells. They are located in the axillae, anal region, scrotum, and labia majora. Their ducts generally open onto hair follicles. The apocrine glands become active at puberty. In women, they enlarge and recede with each menstrual cycle. Apocrine glands produce a milky sweat that is sometimes broken down by bacteria to produce the characteristic underarm odor. Specialized apocrine glands called ceruminous glands are found in the external ear, where they produce cerumen (ie, wax).
FUNCTIONS OF THE SKIN Protection The skin covering most of the body is no more than 1 mm thick, but it provides very effective protection against invasion by bacteria and other foreign matter. The thickened skin of the palms and soles protects against the effects of the constant trauma that occurs in these areas. The epidermis is the outermost layer of the skin and is composed of several layers of keratinocytes that change character as they migrate to the surface. The stratum corneum, the outer layer
of the epidermis, provides the most effective barrier to epidermal water loss and penetration of environmental factors such as chemicals, microbes, and insect bites. Various lipids are synthesized in the stratum corneum and are the basis for the barrier function of this layer. These are longchain lipids that are better suited than phospholipids for water resistance. The presence of these lipids in the stratum corneum creates a relatively impermeable barrier for water egress and for the entry of toxins, microbes, and other substances that come in contact with the surface of the skin. Some substances do penetrate the skin but meet resistance in trying to move through the channels between the cell layers of the stratum corneum. Microbes and fungi, which are part of the body’s normal flora, cannot penetrate unless there is a break in the skin barrier. The dermis–epidermis junction is the basal layer, which is composed of collagen. The basal layer serves four functions. It acts as a scaffold for tissue organization and a template for regeneration; it provides selective permeability for filtration of serum; it is a physical barrier between different types of cells; and it adheres the epithelium to underlying cell layers.
Sensation The receptor endings of nerves in the skin allow the body to constantly monitor the conditions of the immediate environment. The primary functions of the receptors in the skin are to sense temperature, pain, light touch, and pressure (or heavy touch). Different nerve endings respond to each of the different stimuli. Although the nerve endings are distributed over the entire body, they are more concentrated in some areas than in others. For example, the fingertips are more densely innervated than the skin on the back.
Fluid Balance The stratum corneum (ie, outermost layer of the epidermis) has the capacity to absorb water, thereby preventing an excessive loss of water and electrolytes from the internal body and retaining moisture in the subcutaneous tissues. When skin is damaged, as occurs with a severe burn, large quantities of fluids and electrolytes may be lost rapidly, possibly leading to circulatory collapse, shock, and death. The skin is not completely impermeable to water. Small amounts of water continuously evaporate from the skin surface. This evaporation, called insensible perspiration, amounts to approximately 600 mL daily in a normal adult. Insensible water loss varies with the body and ambient temperature. In a person with a fever, the loss can increase. During immersion in water, the skin can accumulate water up to three or four times its normal weight, such as swelling of the skin that occurs after prolonged bathing.
Temperature Regulation The body continuously produces heat as a result of the metabolism of food, which produces energy. This heat is dissipated primarily through the skin. Three major physical processes are involved in loss of heat from the body to the environment. The first process, radiation, is the transfer of heat to another object of
Chapter 55 lower temperature situated at a distance. The second process, conduction, is the transfer of heat from the body to a cooler object in contact with it. Heat transferred by conduction to the air surrounding the body is removed by the third process, convection, which consists of movement of warm air molecules away from the body. Evaporation from the skin aids heat loss by conduction. Heat is conducted through the skin into water molecules on its surface, causing the water to evaporate. The water on the skin surface may be from insensible perspiration, sweat, or the environment. Normally, all of these mechanisms for heat loss are used. When the ambient temperature is very high, however, radiation and convection are ineffective, and evaporation becomes the only means for heat loss. Under normal conditions, metabolic heat production is balanced by heat loss, and the internal temperature of the body is maintained constant at approximately 37°C (98.6°F). The rate of heat loss depends primarily on the surface temperature of the skin, which is a function of the skin blood flow. Under normal conditions, the total blood circulated through the skin is approximately 450 mL per minute, or 10 to 20 times the amount of blood required to provide necessary metabolites and oxygen. Blood flow through these skin vessels is controlled primarily by the sympathetic nervous system. Increased blood flow to the skin results in more heat delivered to the skin and a greater rate of heat loss from the body. In contrast, decreased skin blood flow decreases the skin temperature and helps conserve heat for the body. When the temperature of the body begins to fall, as occurs on a cold day, the blood vessels of the skin constrict, thereby reducing heat loss from the body. Sweating is another process by which the body can regulate the rate of heat loss. Sweating does not occur until the core body temperature exceeds 37°C, regardless of skin temperature. In extremely hot environments, the rate of sweat production may be as high as 1 L per hour. Under some circumstances (eg, emotional stress), sweating may occur as a reflex and may be unrelated to the need to lose heat from the body.
Vitamin Production Skin exposed to ultraviolet light can convert substances necessary for synthesizing vitamin D (cholecalciferol). Vitamin D is essential for preventing rickets, a condition that causes bone deformities and results from a deficiency of vitamin D, calcium, and phosphorus.
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rapidity with which they appear. The outcome is an increasing vulnerability to injury and to certain diseases. Skin problems are common among older people. Before conducting a skin assessment, the nurse needs to be aware of significant changes that occur with aging. The major changes in the skin of older people include dryness, wrinkling, uneven pigmentation, and various proliferative lesions. Cellular changes associated with aging include a thinning at the junction of the dermis and epidermis. This results in fewer anchoring sites between the two skin layers, so that even minor injury or stress to the epidermis can cause it to shear away from the dermis. This phenomenon of aging may account for the increased vulnerability of aged skin to trauma. With increasing age, the epidermis and dermis thin and flatten, causing wrinkles, sags, and overlapping skin folds (Fig. 55-2). Loss of the subcutaneous tissue substances of elastin, collagen, and subcutaneous fat diminishes the protection and cushioning of underlying tissues and organs, decreases muscle tone, and results in the loss of the insulating properties of fat. Cellular replacement slows as a result of aging. As the dermal layers thin, the skin becomes fragile and transparent. The blood supply to the skin also changes with age. Vessels, especially the capillary loops, decrease in number and size. These vascular changes contribute to the delayed wound healing commonly seen in the elderly patient. Sweat and sebaceous glands decrease in number and functional capacity, leading to dry and scaly skin. Reduced hormonal levels of androgens are thought to contribute to declining sebaceous gland function. Hair growth gradually diminishes, especially over the lower legs and dorsum of the feet. Thinning is common in the scalp, axilla, and pubic areas. Other functions affected with normal aging include the barrier function of skin, sensory perception, and thermoregulation. Photoaging, or damage from excessive sun exposure, has detrimental effects on the normal aging of skin. A lifetime of outdoor work or outdoor activities (eg, construction work, lifeguarding, sunbathing) without prudent use of sunscreens can lead to profound wrinkling; increased loss of elasticity; mottled, pigmented areas; cutaneous atrophy; and benign or malignant lesions. Many skin lesions are part of normal aging. Recognizing these lesions enables the examiner to assist the patient to feel less anx-
Immune Response Function Research findings (Demis, 1998) indicate that several dermal cells (ie, Langerhans cells, interleukin-1–producing keratinocytes, and subsets of T lymphocytes) and three varieties of human leukocyte antigen (ie, protein marker on white blood cells indicating the type of cell) are important components of the immune system. Ongoing research is expected to more clearly define the role of these dermal cells in immune function. Gerontologic Considerations The skin undergoes many physiologic changes associated with normal aging. A lifetime of excessive sun exposure, systemic diseases, poor nutrition, and certain medications (eg, antihistamines, diuretics) can enhance the range of skin problems and the
FIGURE 55-2 aging skin.
Hands with wrinkling and overlapping folds common to
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Chart 55-1
Unit 12
INTEGUMENTARY FUNCTION
Benign Changes in Elderly Skin
• Cherry angiomas (bright red “moles”) • Diminished hair, especially on scalp and pubic area • Dyschromias (color variations)
• • • • • • •
Solar lentigo (liver spots) Melasma (dark discoloration of the skin) Lentigines (freckles) Neurodermatitis (itchy spots) Seborrheic keratoses (crusty brown “stuck-on” patches) Spider angiomas Telangiectasias (red marks on skin caused by stretching of the superficial blood vessels) Wrinkles Xerosis (dryness) Xanthelasma (yellowish waxy deposits on upper and lower eyelids)
ious about changes in skin. Chart 55-1 summarizes some skin lesions that are expected to appear as the skin ages. These are normal and require no special attention unless the skin becomes infected or irritated.
Assessment HEALTH HISTORY AND CLINICAL MANIFESTATIONS When caring for patients with dermatologic disorders, the nurse obtains important information through the health history and direct observations. The nurse’s skill in physical assessment and an understanding of the anatomy and function of the skin can ensure that deviations from normal are recognized, reported, and documented. During the health history interview, the nurse asks about any family and personal history of skin allergies, allergic reactions to
GENETICS IN NURSING PRACTICE—Integumentary Conditions Examples of integumentary conditions influenced by genetic factors include the following: • Albinism • Eczema • Hypohidrotic ectodermal dysplasia • Incontinentia pigmenti • Neurofibromatosis type 1 • Pseudoxanthoma elasticum • Psoriasis NURSING ASSESSMENTS FAMILY HISTORY ASSESSMENT
• Assess for other closely related family members with integu-
xanthoma elasticum); Lisch nodules and/or optic glioma (neurofibromatosis type 1). MANAGEMENT ISSUES SPECIFIC TO GENETICS
• Inquire whether DNA mutation or other genetic testing has •
• • •
mentary impairment or abnormalities.
• Inquire about the nature and type of skin lesions and age at
• •
onset (eg, skin involvement with incontinentia pigmenti occurs in the first few weeks of life with blistering of the skin, whereas lesions of neurofibromatosis type 1 may appear in early childhood through adulthood). Note gender of affected individuals (eg, mostly females with incontinentia pigmenti, mostly males with hypohidrotic ectodermal dysplasia). Inquire about the presence of other clinical features, such as unusual hair, teeth, or nails; thrombocytopenia; recurrent infections.
PHYSICAL ASSESSMENT
• Assess for related clinical features, such as sparse eyebrows •
and eyelashes, abnormally shaped teeth, alopecia, nail abnormalities (eg, hypohidrotic ectodermal dysplasia). Assess for related alterations in vision, such as nystagmus, strabismus; albinism; retinal abnormalities (eg, pseudo-
•
been performed on affected family members. If indicated, refer for further genetic counseling and evaluation so that family members can discuss inheritance, risk to other family members, availability of genetic testing, and gene-based interventions. Offer appropriate genetics information and resources. Assess patient’s understanding of genetics information. Provide support to families with newly diagnosed geneticrelated integumentary conditions. Participate in management and coordination of care for patients with genetic conditions and for individuals predisposed to develop or pass on a genetic condition.
GENETICS RESOURCES FOR NURSES AND THEIR PATIENTS ON THE WEB Genetic Alliance—a directory of support groups for patients and families with genetic conditions; http://www.geneticalliance. org Gene Clinics—a listing of common genetic disorders with clinical summaries, genetic counseling and testing information; http://www.geneclinics.org National Organization of Rare Disorders—a directory of support groups and information for patients and families with rare genetic disorders; http://www.rarediseases.org Online Mendelian Inheritance in Man (OMIM)—a complete listing of inherited genetic conditions; http://www.ncbi. nlm.nih.gov/omim/stats/html
Chapter 55 food, medications, chemicals, previous skin problems, and skin cancer. The names of cosmetics, soaps, shampoos, and other personal hygiene products are obtained if there have been any recent skin problems noticed with the use of these products. The health history contains specific information about the onset, signs and symptoms, location, and duration of any pain, itching, rash, or other discomfort experienced by the patient. The accompanying assessment chart lists selected questions useful in obtaining appropriate information (Chart 55-2).
PHYSICAL ASSESSMENT Assessment of the skin involves the entire skin area, including the mucous membranes, scalp, hair, and nails. The skin is a reflection of a person’s overall health, and alterations commonly correspond to disease in other organ systems. Inspection and palpation are techniques commonly used in examining the skin. The room must be well lighted and warm. A penlight may be used to highlight lesions. The patient completely disrobes and is adequately draped. Gloves are worn during skin examination if rash or lesions are to be palpated. However, it is important to avoid making the patient feel as if he or she cannot be touched. Touching skin lesions indicates a level of acceptance of the patient.
Chart 55-2
• ASSESSMENT
Patient History of Skin Disorders Patient history relevant to skin disorders may be obtained by asking the following questions: When did you first notice this skin problem? (Also investigate duration and intensity.) Has it occurred previously? Are there any other symptoms? What site was first affected? What did the rash or lesion look like when it first appeared? Where and how fast did it spread? Do you have any itching, burning, tingling, or crawling sensations? Is there any loss of sensation? Is the problem worse at a particular time or season? How do you think it started? Do you have a history of hay fever, asthma, hives, eczema, or allergies? Who in your family has skin problems or rashes? Did the eruptions appear after certain foods were eaten? Which foods? When the problem occurred, had you recently consumed alcohol? What relation do you think there may be between a specific event and the outbreak of the rash or lesion? What medications are you taking? What topical medication (ointment, cream, salve) have you put on the lesion (including over-the-counter medications)? What skin products or cosmetics do you use? What is your occupation? What in your immediate environment (plants, animals, chemicals, infections) might be precipitating this disorder? Is there anything new, or are there any changes in the environment? Does anything touching your skin cause a rash? How has this affected you (or your life)? Is there anything else you wish to talk about in regard to this disorder?
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Assessing General Appearance The general appearance of the skin is assessed by observing color, temperature, moisture or dryness, skin texture (rough or smooth), lesions, vascularity, mobility, and the condition of the hair and nails. Skin turgor, possible edema, and elasticity are assessed by palpation. Skin color varies from person to person and ranges from ivory to deep brown to almost pure black. The skin of exposed portions of the body, especially in sunny, warm climates, tends to be more pigmented than the rest of the body. The vasodilation that occurs with fever, sunburn, and inflammation produces a pink or reddish hue to the skin. Pallor is an absence of or a decrease in normal skin color and vascularity and is best observed in the conjunctivae or around the mouth. The bluish hue of cyanosis indicates cellular hypoxia and is easily observed in the extremities, nail beds, lips, and mucous membranes. Jaundice, a yellowing of the skin, is directly related to elevations in serum bilirubin and is often first observed in the sclerae and mucous membranes (Fig. 55-3).
Erythema Erythema is redness of the skin caused by the congestion of capillaries. In light-skinned people, it is easily observed at any location where it appears. To determine possible inflammation, the skin is palpated for increased warmth and for smoothness (ie, edema) or hardness (ie, intracellular infiltration). Because dark skin tends to assume a purple-gray cast when an inflammatory process is present, it may be difficult to detect erythema.
Rash In instances of pruritus (ie, itching), the patient should be asked to indicate which areas of the body are involved. The skin is then stretched gently to decrease the reddish tone and make the rash stand out. Pointing a penlight laterally across the skin may effectively highlight the rash. The differences in skin texture are then assessed by running the tips of the fingers lightly over the skin. The borders of the rash may be palpable. The patient’s mouth and ears are included in the examination. (Sometimes rubeola, or measles, causes a red cast to appear on the tip of the ears.) The patient’s temperature is assessed, and the lymph nodes are palpated.
FIGURE 55-3 Examples of skin color changes: the bluish tint of cyanosis (left) and the yellow hue of jaundice (right).
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Unit 12
INTEGUMENTARY FUNCTION
Cyanosis Cyanosis is the bluish discoloration that results from a lack of oxygen in the blood. It appears with shock or with respiratory or circulatory compromise. In people with light skin, cyanosis manifests as a bluish hue to the lips, fingertips, and nail beds. Other indications of decreased tissue perfusion include cold, clammy skin; a rapid, thready pulse; and rapid, shallow respirations. The conjunctivae of the eyelids are examined for pallor and petechiae (ie, pinpoint red spots that appear on the skin as a result of blood leakage into the skin). In a person with dark skin, the skin usually assumes a grayish cast. To detect cyanosis, the areas around the mouth and lips and over the cheekbones and earlobes should be observed.
Color Changes Almost every process that occurs on the skin causes some color change. For example, hypopigmentation (ie, decrease in the melanin of the skin, resulting in a loss of pigmentation) may be caused by a fungal infection, eczema, or vitiligo (ie, condition characterized by destruction of the melanocytes in circumscribed areas of the skin, resulting in white patches). Hyperpigmentation (ie, increase in the melanin of the skin, resulting in increased pigmentation) may occur after disease or injury to the skin (ie, postinflammatory), after sun injury, or as a result of aging. Changes in skin color in people with dark skin are more noticeable and may cause more concern because the discoloration is more readily visible. Some variation in skin pigment levels is considered normal. Examples include the pigmented crease across the bridge of the nose, pigmented streaks in the nails, and pigmented spots on the sclera of the eye. Many variations of color are genetically determined. ASSESSING PATIENTS WITH DARK SKIN The color gradations that occur in people with dark skin are largely determined by genetic transmission; they may be described as light, medium, or dark. In people with dark skin, melanin is produced at a faster rate and in larger quantities than in people with light skin. Healthy dark skin has a reddish base or undertone. The buccal mucosa, tongue, lips, and nails normally are pink. The degree of pigmentation of the patient’s skin may affect the appearance of a lesion. Lesions may be black, purple, or gray instead of the tan or red seen in patients with light skin. Dark pigment responds with discoloration after injury or inflammation, and patients with dark skin more often experience postinflammatory hyperpigmentation than those with lighter skin. The hyperpigmentation eventually fades but may require months to a year to do so. In general, people with dark skin suffer the same skin conditions as those with light skin. They are less likely to have skin cancer but more likely to have keloid or scar formation and disorders resulting from occlusion or blockage of hair follicles. Table 55-2 provides an overview of color changes in lightskinned and dark-skinned people, and the following section provides specific guidelines for assessing dark and light skin. ASSESSING SKIN LESIONS Skin lesions are the most prominent characteristics of dermatologic conditions. They vary in size, shape, and cause and are classified according to their appearance and origin. Skin lesions can
be described as primary or secondary. Primary lesions are the initial lesions and are characteristic of the disease itself. Secondary lesions result from external causes, such as scratching, trauma, infections, or changes caused by wound healing. Depending on the stage of development, skin lesions are further categorized according to type and appearance (Chart 55-3). A preliminary assessment of the eruption or lesion should help to identify the type of dermatosis (ie, abnormal skin condition) and indicate whether the lesion is primary or secondary. At the same time, the anatomic distribution of the eruption should be observed, because certain diseases affect certain sites of the body and are distributed in characteristic patterns and shapes (Figs. 55-4 and 55-5). To determine the extent of the regional distribution, the left and right sides of the body should be compared while the color and shape of the lesions are assessed. After observation, the lesions are palpated to determine their texture, shape, and border and to see if they are soft and filled with fluid or hard and fixed to the surrounding tissue. A metric ruler is used to measure the size of the lesions so that any further extension can be compared with this baseline measurement. The dermatosis is documented on the patient’s health record; it should be described clearly and in detail, using precise terminology. After the characteristic distribution of the lesions has been determined, the following information should be obtained and described clearly and in detail:
• • • • •
Color of the lesion Any redness, heat, pain, or swelling Size and location of the involved area Pattern of eruption (eg, macular, papular, scaling, oozing, discrete, confluent) Distribution of the lesion (eg, bilateral, symmetric, linear, circular)
If acute open wounds or lesions are found on inspection of the skin, a comprehensive assessment should be made and documented in the patient’s record. This assessment should address several issues:
• Wound bed: Inspect for necrotic and granulation tissue, epithelium, exudate, color, and odor.
• Wound edges and margins: Observe for undermining (ie, • •
extension of the wound under the surface skin), and evaluate for condition. Wound size: Measure in millimeters or centimeters, as appropriate, to determine diameter and depth of the wound and surrounding erythema. Surrounding skin: Assess for color, suppleness and moisture, irritation, and scaling.
Assessing Vascularity and Hydration After the color of the skin has been evaluated and lesions have been inspected, an assessment of vascular changes in the skin is performed. A description of vascular changes includes location, distribution, color, size, and the presence of pulsations. Common vascular changes include petechiae, ecchymoses, telangiectases (ie, red marks on the skin caused by stretching of the superficial blood vessels), angiomas, and venous stars. Skin moisture, temperature, and texture are assessed primarily by palpation. The elasticity (ie, turgor) of the skin, which decreases in normal aging, may be a factor in assessing the hydration status of a patient.
Chapter 55
Table 55-2
Assessment of Integumentary Function
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• Color Changes in Light and Dark Skin
ETIOLOGY
LIGHT SKIN
DARK SKIN
Pallor Anemia—decreased hematocrit Shock—decreased perfusion, vasoconstriction
Generalized pallor
Brown skin appears yellow-brown, dull; black skin appears ashen gray, dull. (Observe areas with least pigmentation: conjunctivae, mucous membranes.) Ashen gray, dull; cool to palpation
Local arterial insufficiency Albinism—total absence of pigment melanin Vitiligo—a condition characterized by destruction of the melanocytes in circumscribed areas of the skin (may be localized or widespread) Cyanosis Increased amount of unoxygenated hemoglobin: Central—chronic heart and lung disease cause arterial desaturation Peripheral—exposure to cold, anxiety Erythema Hyperemia—increased blood flow through engorged arterial vessels, as in inflammation, fever, alcohol intake, blushing Polycythemia—increased red blood cells, capillary stasis Carbon monoxide poisoning Venous stasis—decreased blood flow from area, engorged venules Jaundice Increased serum bilirubin concentration (>2–3 mg/100 mL) due to liver dysfunction or hemolysis, as after severe burns or some infections Carotenemia—increased level of serum carotene from ingestion of large amounts of carotene-rich foods Uremia—renal failure causes retained urochrome pigments in the blood Brown-Tan Addison’s disease—cortisol deficiency stimulates increased melanin production
Café-au-lait spots—caused by increased melanin pigment in basal cell layer
Marked localized pallor (lower extremities, especially when elevated) Whitish pink Patchy, milky white spots, often symmetric bilaterally
Dark but dull, lifeless; only severe cyanosis is apparent in skin. (Observe conjunctivae, oral mucosa, nail beds.)
Dusky blue Nail beds dusky
Red, bright pink
Ruddy blue in face, oral mucosa, conjunctivae, hands and feet Bright, cherry red in face and upper torso Dusky rubor of dependent extremities (a prelude to necrosis with pressure ulcer) Yellow first in sclerae, hard palate, and mucous membranes; then over skin
Yellow-orange tinge in forehead, palms and soles, and nasolabial folds, but no yellowing in sclerae or mucous membranes Orange-green or gray overlying pallor of anemia; may also have ecchymoses and purpura Bronzed appearance, an “external tan”; most apparent around nipples, perineum, genitalia, and pressure points (inner thighs, buttocks, elbows, axillae) Tan to light brown, irregularly shaped, oval patch with well-defined borders often not visible in the very dark skinned person
Assessing the Nails and Hair A brief inspection of the nails includes observation of configuration, color, and consistency. Many alterations in the nail or nail bed reflect local or systemic abnormalities in progress or resulting from past events (Fig. 55-6). Transverse depressions known as Beau’s lines in the nails may reflect retarded growth of the nail matrix because of severe illness or, more commonly, local trauma. Ridging, hypertrophy, and other changes may also be visible with
Tan, cream, white Same
Purplish tinge, but difficult to see. (Palpate for increased warmth with inflammation, taut skin, and hardening of deep tissues.) Well concealed by pigment. (Observe for redness in lips.) Cherry red nail beds, lips, and oral mucosa Easily masked. (Use palpation to identify warmth or edema.) Check sclerae for yellow near limbus; do not mistake normal yellowish fatty deposits in the periphery under eyelids for jaundice. (Jaundice is best noted at junction of hard and soft palate, on palms.) Yellow-orange tinge in palms and soles
Easily masked. (Rely on laboratory and clinical findings.)
Easily masked. (Rely on laboratory and clinical findings.)
local trauma. Paronychia, an inflammation of the skin around the nail, is usually accompanied by tenderness and erythema. The angle between the normal nail and its base is 160 degrees. When palpated, the nail base is usually firm. Clubbing is manifested by a straightening of the normal angle (180 degrees or greater) and softening of the nail base. The softened area feels spongelike when palpated. (text continues on page 1650)
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Chart 55-3
Unit 12
INTEGUMENTARY FUNCTION
Primary and Secondary Skin Lesions
PRIMARY SKIN LESIONS Primary skin lesions are original lesions arising from previously normal skin. Secondary lesions can originate from primary lesions and are the progression of the primary disease to a different appearance.
Vesicle
Macule Patch
Macule, Patch Flat, nonpalpable skin color change (color may be brown, white, tan, purple, red) • Macule: 1 cm, may have irregular border Examples: Freckles, flat moles, petechia, rubella, vitiligo, port wine stains, ecchymosis
Papule
Papule, Plaque Elevated, palpable, solid mass Circumscribed border Plaque may be coalesced papules with flat top • Papule: 0.5 cm
Plaque
Bulla Vesicle, Bulla Circumscribed, elevated, palpable mass containing serous fluid • Vesicle: 0.5 cm
Examples: Vesicles: Herpes simplex/zoster, chickenpox, poison ivy, second-degree burn (blister) Bulla: Pemphigus, contact dermatitis, large burn blisters, poison ivy, bullous impetigo
Wheal Wheal • Elevated mass with transient borders • Often irregular • Size and color vary • Caused by movement of serous fluid into the dermis • Does not contain free fluid in a cavity (as, for example, a vesicle does) Examples: Urticaria (hives), insect bites
Examples: Papules: Elevated nevi, warts, lichen planus Plaques: Psoriasis, actinic keratosis
Pustule • Pus-filled vesicle or bulla
Pustule
Examples: Acne, impetigo, furuncles, carbuncles Tumor
Nodule, Tumor Elevated, palpable, solid mass Extends deeper into the dermis than a papule • Nodule: 0.5–2 cm; circumscribed • Tumor: >1–2 cm; tumors do not always have sharp borders Examples: Nodules: Lipoma, squamous cell carcinoma, poorly absorbed injection, dermatofibroma Tumors: Larger lipoma, carcinoma
Cyst • Encapsulated fluid-filled or semisolid mass • In the subcutaneous tissue or dermis
Cyst
Examples: Sebaceous cyst, epidermoid cysts (continued)
Chapter 55
Chart 55-3
Assessment of Integumentary Function
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Primary and Secondary Skin Lesions (Continued)
SECONDARY SKIN LESIONS Secondary skin lesions result from changes in primary lesions.
Erosion • Loss of superficial epidermis • Does not extend to dermis • Depressed, moist area
Erosion
Examples: Ruptured vesicles, scratch marks
Scar (Cicatrix) • Skin mark left after healing of a wound or lesion • Represents replacement by connective tissue of the injured tissue • Young scars: red or purple • Mature scars: white or glistening
Scar
Examples: Healed wound or surgical incision
Ulcer • Skin loss extending past epidermis • Necrotic tissue loss • Bleeding and scarring possible
Ulcer
Examples: Stasis ulcer of venous insufficiency, pressure ulcer
Fissure • Linear crack in the skin • May extend to dermis
Keloid • Hypertrophied scar tissue • Secondary to excessive collagen formation during healing • Elevated, irregular, red • Greater incidence among African Americans
Keloid
Example: Keloid of ear piercing or surgical incision Fissure
Examples: Chapped lips or hands, athlete’s foot
Scales • Flakes secondary to desquamated, dead epithelium • Flakes may adhere to skin surface • Color varies (silvery, white) • Texture varies (thick, fine)
Scales
Atrophy • Thin, dry, transparent appearance of epidermis • Loss of surface markings • Secondary to loss of collagen and elastin • Underlying vessels may be visible
Atrophy
Examples: Aged skin, arterial insufficiency
Examples: Dandruff, psoriasis, dry skin, pityriasis rosea
Crust • Dried residue of serum, blood, or pus on skin surface • Large, adherent crust is a scab Examples: Residue left after vesicle rupture: impetigo, herpes, eczema
Crust
Lichenification • Thickening and roughening of the skin • Accentuated skin markings • May be secondary to repeated rubbing, irritation, scratching
Lichenification
Example: Contact dermatitis (continued)
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Chart 55-3
Unit 12
INTEGUMENTARY FUNCTION
Primary and Secondary Skin Lesions (Continued)
VASCULAR SKIN LESIONS
Petechia (pl. petechiae) • Round red or purple macule • Small: 1–2 mm • Secondary to blood extravasation • Associated with bleeding tendencies or emboli to skin
Ecchymosis (pl. ecchymoses) • Round or irregular macular lesion • Larger than petechia • Color varies and changes: black, yellow, and green hues • Secondary to blood extravasation • Associated with trauma, bleeding tendencies
Cherry Angioma • Papular and round • Red or purple • Noted on trunk, extremities • May blanch with pressure • Normal age-related skin alteration • Usually not clinically significant
Petechiae
Ecchymoses
Spider Angioma • Red, arteriole lesion • Central body with radiating branches Spider angioma • Noted on face, neck, arms, trunk Rare below the waist • • May blanch with pressure • Associated with liver disease, pregnancy, vitamin B deficiency
Telangiectasia (Venous Star) • Shape varies: spider-like or linear • Color bluish or red Telangiectasia • Does not blanch when pressure is applied • Noted on legs, anterior chest • Secondary to superficial dilation of venous vessels and capillaries • Associated with increased venous pressure states (varicosities)
Cherry angioma
The hair assessment is carried out by inspecting and palpating. Gloves are worn, and the examination room should be well lighted. Separating the hair so that the condition of the skin underneath can be easily seen, the nurse assesses color, texture, and distribution. Any abnormal lesions, evidence of itching, inflammation, scaling, or signs of infestation (ie, lice or mites) are documented.
such as thyroid dysfunction. Oily hair is usually caused by increased secretion from the sebaceous glands close to the scalp. If the patient reports a recent change in hair texture, the underlying reason is pursued; the alteration may arise simply from the overuse of commercial hair products or from changing to a new shampoo.
COLOR AND TEXTURE Natural hair color ranges from white to black. Hair color begins to gray with age, initially appearing during the third decade of life, when the loss of melanin begins to become apparent. However, it is not unusual for the hair of younger people to turn gray as a result of hereditary traits. The person with albinism (ie, partial or complete absence of pigmentation) has a genetic predisposition to white hair from birth. The natural state of the hair can be altered by using hair dyes, bleaches, and curling or relaxing products. The types of products used are identified during the assessment. The texture of scalp hair ranges from fine to coarse, silky to brittle, oily to dry, and shiny to dull, and hair can be straight, curly, or kinky. Dry, brittle hair may result from overuse of hair dyes, hair dryers, and curling irons or from endocrine disorders,
DISTRIBUTION Body hair distribution varies with location. Hair over most of the body is fine, except in the axillae and pubic areas, where it is coarse. Pubic hair, which develops at puberty, forms a diamond shape extending up to the umbilicus in boys and men. Female pubic hair resembles an inverted triangle. If the pattern found is more characteristic of the opposite gender, it may indicate an endocrine problem and further investigation is in order. Racial differences in hair are expected, such as straight hair in Asians and curly, coarser hair in people of African descent. Men tend to have more body and facial hair than women. Loss of hair, or alopecia, can occur over the entire body or be confined to a specific area. Scalp hair loss may be localized to patchy areas or may range from generalized thinning to total
Chapter 55
A
Assessment of Integumentary Function
B
A
C
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B
C
D
D
E
F
FIGURE 55-5
Skin lesion configurations. (A) Linear (in a line). (B) Annular and arciform (circular or arcing). (C) Zosteriform (linear along a nerve route). (D) Grouped (clustered). (E) Discrete (separate and distinct). (F) Confluent (merged). From Weber, J. W., & Kelley, J. (2003). Health assessment in nursing (2nd ed.). Philadelphia: Lippincott Williams and Wilkins.
E
F
FIGURE 55-4
Anatomic distribution of common skin disorders. (A) Contact dermatitis (shoes). (B) Contact dermatitis (cosmetics, perfumes, earrings). (C) Seborrheic dermatitis. (D) Acne. (E) Scabies. (F) Herpes zoster (shingles).
baldness. When assessing scalp hair loss, it is important to investigate the underlying cause with the patient. Patchy hair loss may be from habitual hair pulling or twisting; from excessive traction on the hair (eg, braiding too tightly); excessive use of dyes, straighteners, and oils; chemotherapeutic agents (eg, doxorubicin, cyclophosphamide); fungal infection; or moles or lesions on the scalp. Regrowth may be erratic, and distribution may never attain the previous thickness. HAIR LOSS The most common cause of hair loss is male pattern baldness, which affects more than one half of the male population and is believed to be related to heredity, aging, and androgen (male hormone) levels. Androgen is necessary for male pattern baldness to develop. The pattern of hair loss begins with receding of the hairline in the frontal-temporal area and progresses to gradual thinning and complete loss of hair over the top of the scalp and crown. Figure 55-7 illustrates the typical male pattern hair loss.
Beau's lines 180°
Spoon nails >180°
Early clubbing
Late clubbing
Pitting
Paronychia
FIGURE 55-6 Common nail disorders. From Weber, J. W., & Kelley, J. (2003). Health assessment in nursing (2nd ed.). Philadelphia: Lippincott Williams and Wilkins.
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FIGURE 55-7
INTEGUMENTARY FUNCTION
The progression of male pattern baldness.
OTHER CHANGES Male pattern hair distribution may be seen in some women at the time of menopause, when the hormone estrogen is no longer produced by the ovaries. In women with hirsutism, excessive hair may grow on the face, chest, shoulders, and pubic area. When menopause is ruled out as the underlying cause, hormonal abnormalities related to pituitary or adrenal dysfunction must be investigated. Because patients with skin conditions may be viewed negatively by others, these patients may become distraught and avoid interaction with people. Skin conditions can lead to disfigurement, isolation, job loss, and economic hardship. Some conditions may subject the patient to a protracted illness, leading to feelings of depression, frustration, self-consciousness, poor self-image, and rejection. Itching and skin irritation, features of many skin diseases, may be a constant annoyance. The results of these discomforts may be loss of sleep, anxiety, and depression, all of which reinforce the general distress and fatigue that frequently accompany skin disorders. For patients suffering such physical and psychological discomforts, the nurse needs to provide understanding, explanations of the problem, appropriate instructions related to treatment, nursing support, patience, and encouragement. It takes time to help patients gain insight into their problems and resolve their difficulties. It is imperative to overcome any aversion that may be felt when caring for patients with unattractive skin disorders. The nurse should show no sign of hesitancy when approaching patients with skin disorders. Such hesitancy only reinforces the psychological trauma of the disorder.
formed on skin nodules, plaques, blisters, and other lesions to rule out malignancy and to establish an exact diagnosis.
Diagnostic Evaluation
TZANCK SMEAR
In addition to obtaining the patient’s history, the examiner inspects the primary and secondary lesions and their configuration and distribution. Certain diagnostic procedures may also be used to help identify skin conditions.
SKIN BIOPSY Performed to obtain tissue for microscopic examination, a skin biopsy may be obtained by scalpel excision or by a skin punch instrument that removes a small core of tissue. Biopsies are per-
IMMUNOFLUORESCENCE Designed to identify the site of an immune reaction, immunofluorescence testing combines an antigen or antibody with a fluorochrome dye. Antibodies can be made fluorescent by attaching them to a dye. Direct immunofluorescence tests on skin are techniques to detect autoantibodies directed against portions of the skin. The indirect immunofluorescence test detects specific antibodies in the patient’s serum.
PATCH TESTING Performed to identify substances to which the patient has developed an allergy, patch testing involves applying the suspected allergens to normal skin under occlusive patches. The development of redness, fine bumps, or itching is considered a weak positive reaction; fine blisters, papules, and severe itching indicate a moderately positive reaction; and blisters, pain, and ulceration indicate a strong positive reaction (see Chap. 53).
SKIN SCRAPINGS Tissue samples are scraped from suspected fungal lesions with a scalpel blade moistened with oil so that the scraped skin adheres to the blade. The scraped material is transferred to a glass slide, covered with a coverslip, and examined microscopically.
The Tzanck smear is a test used to examine cells from blistering skin conditions, such as herpes zoster, varicella, herpes simplex, and all forms of pemphigus. The secretions from a suspected lesion are applied to a glass slide, stained, and examined.
WOOD’S LIGHT EXAMINATION Wood’s light is a special lamp that produces long-wave ultraviolet rays, which result in a characteristic dark purple fluorescence. The color of the fluorescent light is best seen in a darkened room, where it is possible to differentiate epidermal from dermal
Chapter 55 lesions and hypopigmented and hyperpigmented lesions from normal skin. The patient is reassured that the light is not harmful to skin or eyes. Lesions that still contain melanin almost disappear under ultraviolet light, whereas lesions that are devoid of melanin increase in whiteness with ultraviolet light.
CLINICAL PHOTOGRAPHS Photographs are taken to document the nature and extent of the skin condition and are used to determine progress or improvement resulting from treatment.
?
Critical Thinking Exercises
1.
In thinking about the skin as the first line of defense for homeostasis, identify some of the threats to skin integrity that should be assessed when admitting a patient to the hospital. What impact does the type of skin care delivered have on skin integrity? How would skin assessment of an elderly patient differ from that of a young adult?
2.
An elderly African American woman is admitted to the hospital for treatment of diabetes. What concerns should be addressed relative to the skin and circulation in a patient with diabetes? How will your assessment of the skin of this patient differ from the assessment of the skin of a Caucasian patient?
REFERENCES AND SELECTED READINGS Books Bickley, L. S., & Szilagyi, P. G. (2003). Bates’ guide to physical examination and history taking (8th ed.). Philadelphia: Lippincott Williams & Williams. Champion, R. H., Burton, J. L., Burns, D. A., & Breathnach, S. M. (1998). Rook/Wilkinson/Ebling textbook of dermatology (6th ed.). Boston: Blackwell Science. Demis, D. J. (Ed.). (1998). Clinical dermatology. Philadelphia: LippincottRaven. Fitzpatrick, T. B., et al. (1997). Color atlas & synopsis of clinical dermatology (3rd ed.). New York: McGraw-Hill. Freedberg, I. M., Eisen, A. Z., Austen, K. F., Goldsmith, S. I., Katz, S., & Fitzpatrick, T. B. (1999). Fitzpatrick’s dermatology in general medicine (5th ed.). New York: McGraw-Hill. Odom, R. B., James, W. D., & Berger, T. G. (2000). Andrews’ diseases of the skin (9th ed.). Philadelphia: W. B. Saunders.
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Weber, J. W., & Kelley, J. (2003). Health assessment in nursing (2nd ed.). Philadelphia: Lippincott Williams & Wilkins.
Journals Draelos, Z. D. (1997). Understanding African-American hair. Dermatology Nursing, 9(4), 227–231. Fleischer, A. B., Feldman, S. R., & Rapp, S. R. (2000). The magnitude of skin disease in the United States. Dermatologic Clinics, 17(2), 322–327. Jaworski, C., & Gilliam, A. C. (1999). Immunopathology of the hair follicle. Dermatologic Clinics, 17(3), 561–568. Kang, S. (2001). Photoaging: Pathogenesis, prevention and treatment. Clinical Geriatric Medicine, 17(4), 643–659. Sun-protection behaviors used by adults for their children: U.S. (1998). Morbidity and Mortality Weekly Report, 47(23), 48–52. Weinstock, M. A., & Rossi, J. S. (1998). The Rhode Island Sun Smart Project: A scientific approach to skin cancer prevention. Clinical Dermatology, 16(4), 411–413.
RESOURCES AND WEBSITES Dermatology online atlas, a cooperation between the Department of Clinical Social Medicine (University of Heidelberg) and the Department of Dermatology (University of Erlangen); http://www.dermis.net. Foundation for Ichthyosis and Related Skin Types, 650 N. Cannon Avenue, Suite 17, Lansdale, PA 19446; 215-631-1411; http://www. scalyskin.org. Lupus Foundation, 1300 Piccard Dr., Rockville, MD 29850-4303; 301670-9292; http://www.lupus.org. Medscape online sources for medical information; http://www. medscape.com. National Alopecia Areata Foundation (NAAF), P.O. Box 150760, San Rafael, CA 94915-0760; 415-472-3780; http://www.alopecia areata.com. National Eczema Association for Science and Education, 1220 S. W. Morrison, Suite 433, Portland, OR 97205; 415-499-3474; http:// www.eczema-assn.org. National Organization for Albinism and Hypopigmentation, P.O. Box 959, East Hampstead, NH 03826-0959; 800-473-2310; http://www. albinism.org. National Pressure Ulcer Advisory Panel, 11250 Roger Bacon Dr., Suite 8, Reston, VA 20190-5202; 703-464-4849; http://www.npuap.org. National Psoriasis Foundation (USA), 6600 S.W. 92nd Ave., Suite 300, Portland, OR 97223-7195; 503-244-7404; http://www.psoriasis.org. National Rosacea Society, 800 South Northwest Highway, Suite 200, Barrington, IL 60010; 1-888-NO-BLUSH; http://www.rosacea.org. National Vitiligo Foundation, 611 South Fleishel Ave., Tyler, TX 75701; 903-531-0074; http://www.nvfi.org. Neutrogena and Orthopharmaceuticals Products: 1-800-582-4048; http://www.neutrogena.com. New Zealand Dermatology Society; http://www.dermnetnz.org. Skin Cancer Foundation, 575 Park Ave. S., New York, NY 10016; 1-800-SKIN-490; http://www.skincancer.org.
Chapter
56 ●
Management of Patients With Dermatologic Problems
LEARNING OBJECTIVES
●
On completion of this chapter, the learner will be able to: 1. Describe the general management of the patient with an abnormal 2. 3. 4. 5. 6. 7. 8. 9.
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skin condition. Use the nursing process as a framework for care of the patient with psoriasis. Describe the health education needs of the patient with infections of the skin and parasitic skin diseases. Use the nursing process as a framework for care of patients with noninfectious, inflammatory dermatoses. Describe the management and nursing care of the patient with skin cancer. Use the nursing process as a framework for care of the patient with malignant melanoma. Describe characteristics of the various types of Kaposi’s sarcoma. Compare the various types of dermatologic and plastic reconstructive surgeries. Use the nursing process as a framework for care of the patient undergoing facial reconstructive surgery.
N
Chapter 56
ursing care for patients with dermatologic problems includes administering topical and systemic medications, managing wet dressings and other special dressings, and providing therapeutic baths. The four major objectives of therapy are to prevent additional damage, prevent secondary infection, reverse the inflammatory process, and relieve the symptoms.
Skin Care for Patients With Skin Conditions Some skin problems are markedly aggravated by soap and water, and bathing routines are modified according to the condition. Denuded skin, whether the area of desquamation is large or small, is excessively prone to damage by chemicals and trauma. The friction of a towel, if applied with vigor, is sufficient to produce a brisk inflammatory response that causes any existing lesion to flare up and extend.
Protecting the Skin The essence of skin care and protection in bathing a patient with skin problems is as follows: a mild, lipid-free soap or soap substitute is used; the area is rinsed completely and blotted dry with a soft cloth; and deodorant soaps are avoided. Special care is necessary when changing dressings. Pledgets saturated with oil, sterile saline, or another prescribed solution help to loosen crusts, remove exudates, or free an adherent dry dressing.
Management of Patients With Dermatologic Problems
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swollen) and oozing, it is best to apply wet dressings and soothing lotions. For chronic conditions in which the skin surface is dry and scaly, water-soluble emulsions, creams, ointments, and pastes are used. The therapy is modified as the responses of the skin indicate. The patient and the nurse should note whether the medication or dressings seem to irritate the skin. The success or failure of therapy usually depends on adequate instruction and motivation of the patient and the interest of and support by the health care personnel.
Wound Care for Skin Conditions There are three major classifications of dressings for skin conditions: wet, moisture-retentive, and occlusive. During the 1980s and 1990s, new product development quadrupled the available choices for wound care, especially within the moisture-retentive dressing classification. Products classified as moisture-retentive dressings include hydrogels, foams, and alginates. Biologicals and biosynthetics containing collagen and growth factor are being researched and will soon be available. Chart 56-1 lists generic wound care products. Consultation with a wound care specialist can be very helpful in choosing the product most appropriate for the patient.
Dressings and Rules of Wound Care Even with the increased availability of dressings, an appropriate selection can be made if certain principles are maintained, referred to as the five rules of wound care (Krastner, et al, 2002).
Preventing Secondary Infection Potentially infectious skin lesions should be regarded strictly as such, and proper precautions should be observed until the diagnosis is established. Most lesions with pus contain infectious material. The nurse and physician must adhere to standard precautions and wear gloves when inspecting the skin or changing the dressing. Proper disposal of any contaminated dressing is carried out according to Occupational Safety and Health Administration (OSHA) regulations.
Reversing the Inflammatory Process The type of skin lesion (eg, oozing, infected, or dry) usually determines the type of local medication or treatment that is prescribed. As a rule, if the skin is acutely inflamed (ie, hot, red, and
Rule 1: Categorization. The nurse should learn about dressings by generic category and compare new products with those that already make up the category. As hundreds of choices become available, the nurse should become familiar with the generic categories and develop a systematic approach to product selection. The nurse should become familiar with indications, contraindications, and side effects. The best dressing may be created by combining products in different categories to achieve several goals at the same time. These categories are discussed in subsequent sections. Rule 2: Selection. The nurse should select the safest and most effective, user-friendly, and cost-effective dressing possible. In
Glossary acantholysis: separation of epidermal cells from each other due to damage or abnormality of the intracellular substance balneotherapy: a bath with therapeutic additives carbuncle: localized skin infection involving several hair follicles cheilitis: dry, cracking, inflamed skin at the corners of the mouth comedones: the primary lesions of acne, caused by sebum blockage in the hair follicle débridement: removal of necrotic or dead tissue by mechanical, surgical, or autolytic means
dermatitis: any inflammation of the skin dermatosis: any abnormal skin lesion epidermopoiesis: development of epidermal cells furuncle: localized skin infection of a single hair follicle hydrophilic: a material that absorbs moisture hydrophobic: a material that repels moisture hygroscopic: a material that absorbs moisture from the air lichenification: thickening of the horny layer of the skin liniments: lotions with added oil for increased softening of the skin
plasmapheresis: removal of whole blood from the body, separation of its cellular elements by centrifugation, and reinfusion of them suspended in saline or some other plasma substitute, thereby depleting the body’s own plasma without depleting its cells Propionibacterium acnes: bacteria that live on the skin; the primary causative agent of acne pyodermas: bacterial skin infections suspensions: liquid preparations in which powder is suspended, requiring shaking before use tinea: a superficial fungal infection on the skin or scalp
Unit 12
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Chart 56-1
INTEGUMENTARY FUNCTION
Wound Care Products
adhesives adhesive removers adhesive skin closures adhesive tapes alginate dressings antibiotics antimicrobials antiseptics bandages biosynthetic dressings cleansers collagen dressings composite dressings contact layers
creams or skin protectant pastes dressing covers enzyme débriding agents foam dressings gauze dressings growth factors hydrocolloid dressings hydrogel dressings leg ulcer wraps, compression bandages or wraps
lubricating, stimulating sprays moisturizers moisture barrier ointments ointments perineal cleansers skin sealants transparent film dressings wound fillers: pastes, powders, beads, etc. wound pouches
(thereby decreasing vasodilation and local blood flow in inflammation); to clean the skin of exudates, crusts, and scales; to maintain drainage of infected areas; and to promote healing by facilitating the free movement of epidermal cells across the involved skin so that new granulation tissue forms. Wet dressings can be used for vesicular, bullous, pustular, and ulcerative disorders, as well as for inflammatory conditions. Before applying these dressings, the nurse performs hand hygiene and puts on sterile or clean gloves. The open dressing requires frequent changes because evaporation is rapid. The closed dressing is changed less frequently, but there is always a danger that the closed dressing may cause not only softening and but actual maceration of the underlying skin. Wet-to-dry dressings are used to remove exudate from erosions or ulcers. The dressing remains in place until it dries. It is then removed without soaking so that crusts, exudate, or pus from the skin lesion adhere to the dressing and are removed with it.
Moisture-Retentive Dressings many cases, nurses carry out the physician’s prescriptions for dressings, but they should be prepared to give the physician feedback about the dressing’s effect on the wound, ease of use for the patient, and other considerations when applicable. Rule 3: Change. The nurse changes dressings based on patient, wound, and dressing assessments, not on standardized routines. Traditional nursing care plans recommended changing dressings on a routine schedule, often three or four times each day.
!
NURSING ALERT It is believed that the natural wound-healing process should not be disrupted. Unless the wound is infected or has a heavy discharge, it is common to leave chronic wounds covered for 48 to 72 hours and acute wounds for 24 hours.
Rule 4: Evolution. As the wound progresses through the phases of wound healing, the dressing protocol is altered to optimize wound healing. It is rare, especially in cases of chronic wounds, that the same dressing material is appropriate throughout the healing process. The rule assumes that the nurse and the patient or family have access to a wide variety of products and knowledge about their use. The nurse teaches the patient or family caregiver about wound care and ensures that the family has access to appropriate dressing choices. Rule 5: Practice. Practice with dressing material is required for the nurse to learn the performance parameters of the particular dressing. Refining the skills of applying appropriate dressings correctly and learning about new dressing products are essential nursing responsibilities. Dressing changes should not be delegated to assistive personnel; these techniques require the knowledge base and assessment skills of professional nurses.
Wet Dressings Wet dressings (ie, wet compresses applied to the skin) were traditionally used for acute, weeping, inflammatory lesions. They have become almost obsolete in light of the many newer products available for wound care. Wet dressings are sterile or nonsterile (clean), depending on the skin disorder. They are used to reduce inflammation by producing constriction of the blood vessels
Newer, commercially produced moisture-retentive dressings can perform the same functions as wet compresses but are more efficient at removing exudate because of their higher moisture-vapor transmission rate; some have reservoirs that can hold excessive exudate. There is also evidence that moist wound healing results in wound resurfacing 40% faster than with air exposure. A number of moisture-retentive dressings are already impregnated with saline solution, petrolatum, zinc-saline solution, hydrogel, or antimicrobial agents, thereby eliminating the need to coat the skin to avoid maceration. The main advantages of moisture-retentive dressings over wet compresses are reduced pain, fewer infections, less scar tissue, gentle autolytic débridement, and decreased frequency of dressing changes. Depending on the product used and the type of dermatologic problem encountered, most moistureretentive dressings may remain in place from 12 to 24 hours; some can remain in place as long as a week. Table 56-1 is a guide to wound dressing functions and categories. Hydrogels are polymers with a 90% to 95% water content. They are available in impregnated sheets or as gel in a tube. Their high moisture content makes them ideal for autolytic débridement of wounds. They are semitransparent, allowing for wound inspection without dressing removal. They are comfortable and soothing for the painful wound. They have no inherent adhesive and require a secondary dressing to keep them in place. Hydrogels are appropriate for superficial wounds with high serous output, such as abrasions, skin graft sites, and draining venous ulcers. Hydrocolloids are composed of a water-impermeable, polyurethane outer covering separated from the wound by a hydrocolloid material. They are adherent and nonpermeable to water vapor and oxygen. As it evaporates over the wound, water is absorbed into the dressing, which softens and discolors with the increased water content. The dressing can be removed without damage to the wound. As the dressing absorbs water, it produces a foul-smelling, yellowish covering over the wound. This is a normal chemical interaction between the dressing and wound exudate and should not be confused with purulent drainage from the wound. Unfortunately, most of the hydrocolloid dressings are opaque, limiting inspection of the wound without removal of the dressing. Available in sheets and in gels, hydrocolloids are a good choice for exudative wounds and for acute wounds. Easy to use and comfortable, hydrocolloid dressings promote débridement and formation of granulation tissue. They do not have to be removed for bathing. Most can be left in place for up to 7 days.
Chapter 56
Table 56-1
Management of Patients With Dermatologic Problems
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• Quick Guide to Wound Dressing Function and Categories
FUNCTION
ACTION
EXAMPLE
Absorption
Absorbs exudate
Cleansing
Removes purulent drainage, foreign debris, and devitalized tissue Autolytic; covers a wound and allows enzymes to self-digest sloughed skin
Alginates, composite dressings, foams, gauze, hydrocolloids, hydrogels Wound cleansers
Débridement
Diathermy Hydration
Chemical or enzymatic; applied topically to break down devitalized tissue Mechanical; removes devitalized tissue with mechanical force Produces electrical current to promote warmth and new tissue growth Adds moisture to a wound
Maintain moist environment
Manages moisture levels in a wound and maintains a moist environment
Manage high-output wounds Pack or fill dead space
Manages excessive quantities of exudate Prevents premature wound closure or fills shallow areas and provides absorption
Protect and cover wound
Provides protection from the external environment
Prevents moisture and mechanical trauma from damaging delicate tissue around wound Provide therapeutic compression Provides appropriate levels of support to the lower extremities in venous stasis disease Protect periwound skin
Foam dressings consist of microporous polyurethane with an absorptive hydrophilic (ie, water-absorbing) surface that covers the wound and a hydrophobic (ie, water-resistant) backing to block leakage of exudate. They are nonadherent and require a secondary dressing to keep them in place. Moisture is absorbed into the foam layer, decreasing maceration of surrounding tissue. A moist environment is maintained, and removal of the dressing does not damage the wound. The foams are opaque and must be removed for wound inspection. Foams are a good choice for exudative wounds. They are especially helpful over bony prominences because they provide contoured cushioning. Calcium alginates are derived from seaweed and consist of tremendously absorbent calcium alginate fibers. They are hemostatic and bioabsorbable and can be used as sheets, mats, or ropes of absorbent material. As the exudate is absorbed, the fibers turn into a viscous hydrogel. They are quite useful in areas where the tissue is more irritated or macerated. The alginate dressing forms a moist pocket over the wound while the surrounding skin stays dry. They also react with wound fluid to form a foul-smelling coating. Alginates work well when packed into a deep cavity, wound, or sinus tract with heavy drainage (Krastner et al, 2002). They are nonadherent and require a secondary dressing.
Absorption beads, pastes, powders; alginates; composite dressings; foams; hydrate gauze; hydrogels; hydrocolloids; transparent films; wound care systems Enzymatic débridement agents Wound cleansers, gauze (wet to dry), whirlpool
Gauze (saturated with saline) solution, hydrogels, wound care systems, fibrous fleece dressings Composites, contact layers, foams, gauze (impregnated or saturated), hydogels, hydrocolloids, transparent films, wound care systems Pouching systems Absorbent beads, powders, pastes; alginates, composites, foams, gauze (impregnated and nonimpregnated) Composites, compression bandages/wraps, foams, gauze dressings, hydrogels, hydrocolloids, transparent film dressings Composites, foams, hydrocolloids, pouching systems, skin sealants, transparent film dressings Compression bandages, wraps
Occlusive Dressings Occlusive dressings may be commercially produced or made inexpensively from sterile or nonsterile gauze squares or wrap. Occlusive dressings cover topical medication that is applied to a dermatosis (ie, abnormal skin lesion). The area is kept airtight by using plastic film (eg, plastic wrap). Plastic film is thin and readily adapts to all sizes, body shapes, and skin surfaces. Plastic surgical tape containing a corticosteroid in the adhesive layer can be cut to size and applied to individual lesions. Generally, plastic wrap should be used no more than 12 hours each day. AUTOLYTIC DÉBRIDEMENT Autolytic débridement is a process that uses the body’s own digestive enzymes to break down necrotic tissue. The wound is kept moist with occlusive dressings. Eschar and necrotic debris are softened, liquefied, and separated from the bed of the wound. Several commercially available products contain the same enzymes that the body produces naturally. These are called enzymatic débriding agents; examples include Accu Zyme, collagenase (Santyl), Granulex, and Zymase. Application of these products speeds the rate at which necrotic tissue is removed. This method is still slower and no more effective than surgical débridement. When enzymatic débridment is being used under an occlusive
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Unit 12
INTEGUMENTARY FUNCTION
dressing, a foul odor is produced by the breakdown of cellular debris. This odor does not indicate that the wound is infected. The nurse should expect this reaction, and help the patient understand the reason for the odor.
Advances in Wound Treatment Increasing understanding of how skin heals has led to several advances in therapy. Growth factors are cytokines or proteins that have potent mitogenic activity (Valencia et al., 2001). Low levels of cytokines circulate in the blood continuously, but activated platelets release increased amounts of preformed growth factors into a wound. This increase in cytokines in the wound stimulates cellular growth and granulation of skin. Regranex gel contains becaplermin, a platelet-derived growth factor, which is applied to the wound to stimulate healing. Apligraf is a skin construct (ie, bioengineered skin substitute) imbedded in a dressing that also contains cytokines and fibroblasts. When applied to wounds, these agents stimulate platelet activity and potentially decrease wound healing time (Paquette & Falanga, 2002). Some oral medications are being investigated for their benefits in healing chronic venous ulcers of the lower legs. Pentoxifylline (Trental) increases peripheral blood flow by decreasing the viscosity of blood. It has some fibrinolytic action and decreases leukocyte adhesion to the wall of the blood vessels. Enteric-coated aspirin has also been shown to be of value, although its exact mechanism is still not clear (Valencia et al., 2001).
Medical Management THERAPEUTIC BATHS (BALNEOTHERAPY) AND MEDICATIONS Baths or soaks, known as balneotherapy, are useful when large areas of skin are affected. The baths remove crusts, scales, and old medications and relieve the inflammation and itching that accompany acute dermatoses. The water temperature should be comfortable, and the bath should not exceed 20 to 30 minutes because of the tendency of baths and soaks to produce skin maceration. Table 56-2 lists the different types of therapeutic baths and their uses.
Table 56-2
PHARMACOLOGIC THERAPY Because skin is easily accessible and therefore easy to treat, topical medications are often used. High concentrations of some medications can be applied directly to the affected site with little systemic absorption and therefore with few systemic side effects. However, some medications are readily absorbed through the skin and can produce systemic effects. Because topical preparations may induce allergic contact dermatitis (ie, inflammation of the skin) in sensitive patients, any untoward response should be reported immediately and the medication discontinued. Medicated lotions, creams, ointments, and powders are frequently used to treat skin lesions. In general, moisture-retentive dressings, with or without medication, are used in the acute stage; lotions and creams are reserved for the subacute stage; and ointments are used when inflammation has become chronic and the skin is dry with scaling or lichenification (ie, leathery thickening). With all types of topical medication, the patient is taught to apply the medication gently but thoroughly and, when necessary, to cover the medication with a dressing to protect clothing. Table 56-3 lists some commonly used topical preparations. Lotions. Lotions are of two types: suspensions and liniments. Suspensions consist of a powder in water, requiring shaking before application, and clear solutions, containing completely dissolved active ingredients. Lotions are usually applied directly to the skin, but a dressing soaked in the lotion can be placed on the affected area. A suspension such as calamine lotion provides a rapid cooling and drying effect as it evaporates, leaving a thin, medicinal layer of powder on the affected skin. Lotions are frequently used to replenish lost skin oils or to relieve pruritus. Lotions must be applied every 3 or 4 hours for sustained therapeutic effect. If left in place for a longer period, they may crust and cake on the skin. Liniments are lotions with oil added to prevent crusting. Because lotions are easy to use, therapeutic compliance is generally high. Powders. Powders usually have a talc, zinc oxide, bentonite, or cornstarch base and are dusted on the skin with a shaker or with cotton sponges. Although their therapeutic action is brief, powders act as hygroscopic agents that absorb and retain moisture from the air and reduce friction between skin surfaces and clothing or bedding.
• Types of Therapeutic Baths
BATH SOLUTION
EFFECTS AND USES
NURSING INTERVENTIONS
Water Saline Colloidal (Aveeno, oatmeal) Sodium bicarbonate (baking soda) Starch Medicated tars Bath oils
Same effect as wet dressings Used for widely disseminated lesions Antipruritic, soothing Cooling Soothing Psoriasis and chronic eczema Antipruritic and emollient action; acute and subacute generalized eczematous eruptions
• • • • • • • • •
Fill the tub half full. Keep the water at a comfortable temperature. Do not allow the water to cool excessively. Use a bath mat—medications added to bath can cause the tub to be slippery. Apply an emollient cream to damp skin after the bath if lubrication is desired. Because tars are volatile, the bath area should be well ventilated. Dry by gently blotting with a towel. Keep room warm to minimize temperature fluctuations. Encourage the patient to wear light, loose clothing after the bath.
Chapter 56
Table 56-3 • PREPARATION
Bath preparations With tar With colloidal oatmeal With oatmeal and mineral oil With mineral oil Moisturizer creams
Moisturizer ointments Topical anesthetics
Topical antibiotics
Common Topical Preparations and Medications PRODUCT NAME
Balnetar, Doak Oil, Lavatar Aveeno Oilated Bath Powder Aveeno Bath Oil, Nutra Soothe Nutraderm Bath Oil, Lubath, AlphaKeri Bath Oil Acid Mantle Cream, Curel Cream, Dermasil, Eucerin, Lubriderm, Noxzema Skin Cream Aquaphor Ointment, Eutra Swiss Skin Cream, Vaseline Ointment lidocaine (Xylocaine) of various strengths in the form of spray, ointment, gel; EMLA cream (lidocaine 2.5% and prilocaine 2.5%) bacitracin, Polysporin (bacitracin and polymixin B), Bactroban ointment or cream (mupirocin 2%), erythromycin 2% (Emgel, Eryderm Solution), clindamycin phosphate 1% (Cleocin cream, gel, solution), gentamicin sulfate 1% (Garamycin cream or ointment), 1% silver sulfadiazine cream (Silvadene)
Creams. Creams may be suspensions of oil in water or emulsions of water in oil, with additional ingredients to prevent bacterial and fungal growth. Both may cause an allergic reaction such as contact dermatitis. Oil-in-water creams are easily applied and usually are the most cosmetically acceptable to the patient. Although they can be used on the face, they tend to have a drying effect. Water-inoil emulsions are greasier and are preferred for drying and flaking dermatoses. Creams usually are rubbed into the skin by hand. They are used for their moisturizing and emollient effects. Gels. Gels are semisolid emulsions that become liquid when applied to the skin or scalp. They are cosmetically acceptable to the patient because they are not visible after application, and they are greaseless and nonstaining. The newer water-based gels appear to penetrate the skin more effectively and cause less stinging on application. They are especially useful for acute dermatitis in which there is weeping exudate (eg, poison ivy). Pastes. Pastes are mixtures of powders and ointments and are used in inflammatory blistering conditions. They adhere to the skin and may be difficult to remove without using an oil (eg, olive oil, mineral oil). Pastes are applied with a wooden tongue depressor or gloved hand. Ointments. Ointments retard water loss and lubricate and protect the skin. They are the preferred vehicle for delivering medication to chronic or localized dry skin conditions, such as eczema or psoriasis. Ointments are applied with a wooden tongue depressor or by hand (gloved).
Management of Patients With Dermatologic Problems
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Sprays and Aerosols. Spray and aerosol preparations may be used on any widespread dermatologic condition. They evaporate on contact and are used infrequently. Corticosteroids. Corticosteroids are widely used in treating dermatologic conditions to provide anti-inflammatory, antipruritic, and vasoconstrictive effects. The patient is taught to apply this medication according to strict guidelines, using it sparingly but rubbing it into the prescribed area thoroughly. Absorption of topical corticosteroid is enhanced when the skin is hydrated or the affected area is covered by an occlusive or moisture-retentive dressing. Inappropriate use of topical corticosteroids can result in local and systemic side effects, especially when the medication is absorbed through inflamed and excoriated skin, under occlusive dressings, or when used for long periods on sensitive areas. Local side effects may include skin atrophy and thinning, striae (ie, bandlike streaks), and telangiectasia. Thinning of the skin results from the ability of corticosteroids to inhibit skin collagen synthesis (Odom et al., 2000). The thinning process can be reversed by discontinuing the medication, but striae and telangiectasia are permanent. Systemic side effects may include hyperglycemia and symptoms of Cushing’s syndrome. Caution is required when applying corticosteroids around the eyes because long-term use may cause glaucoma or cataracts, and the anti-inflammatory effect of corticosteroids may mask existing viral or fungal infections. Concentrated (fluorinated) corticosteroids are never applied on the face or intertriginous areas (ie, axilla and groin), because these areas have a thinner stratum corneum and absorb the medication much more quickly than areas such as the forearm or legs. Persistent use of concentrated topical corticosteroids in any location may produce acnelike dermatitis, known as steroid-induced acne, and hypertrichosis (ie, excessive hair growth). Because some topical corticosteroid preparations are available without prescription, patients should be cautioned about prolonged and inappropriate use. Table 56-4 lists topical corticosteroid preparations according to potency. Intralesional Therapy. Intralesional therapy consists of injecting a sterile suspension of medication (usually a corticosteroid) into or just below a lesion. Although this treatment may have an antiinflammatory effect, local atrophy may result if the medication is injected into subcutaneous fat. Skin lesions treated with intralesional therapy include psoriasis, keloids, and cystic acne. Occasionally, immunotherapeutic and antifungal agents are administered as intralesional therapy. Systemic Medications. Systemic medications are also prescribed for skin conditions. These include corticosteroids for short-term therapy for contact dermatitis or for long-term treatment of a chronic dermatosis, such as pemphigus vulgaris. Other frequently used systemic medications include antibiotics, antifungals, antihistamines, sedatives, tranquilizers, analgesics, and cytotoxic agents.
Nursing Management Management begins with a health history, direct observation, and a complete physical examination. Chapter 55 provides a description of integumentary assessment. Because of its visibility, a skin condition is usually difficult to ignore or conceal from others and may therefore cause the patient some emotional distress. The major goals for the patient may include maintenance of skin integrity, relief of discomfort, promotion of restful sleep, self-acceptance, knowledge about skin care, and avoidance of complications.
Unit 12
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Table 56-4
INTEGUMENTARY FUNCTION
• Potency: Topical Corticosteroids
POTENCY
TOPICAL CORTICOSTEROID
PREPARATIONS
OTC Lowest
0.5–1.0% hydrocortisone dexamethasone 0.1% (Decaderm) alclometasone 0.05% (Aclovate) hydrocortisone 2.5% (Hytone) desonide 0.05% (DesOwen, Tridesilon) fluocinolone acetonide 0.025% (Synalar) hydrocortisone valerate 0.2% (Westcort) betamethasone valerate 0.1% (Valisone) fluticasonepropionate 0.05% (Cutivate) triamcinolone acetonide 0.1–0.5% (Aristocort) fluocinonide 0.05% (Lidex) desoximetasone 0.05–0.25% (Topicort) fluocinolone 0.2% (Synalar) diflorasone diacetate 0.05% (Psorcon) clobetasol propionate 0.05% (Temovate) betamethasone dipropionate 0.05% (Diprolene) halobetasole propionate 0.05% (Ultravate)
cr, lot, oint* cr, oint, aerosol, gel
Low–medium
Medium–high
Very high
cr, oint cr, lot, oint cr, lot, oint
perineal areas. Axillary dressings can be made of cotton cloth, or a commercially prepared dressing may be used and taped in place or held by dress shields. A turban or plastic shower cap is useful for holding dressings on the scalp. A face mask, made from gauze with holes cut out for the eyes, nose, and mouth, may be held in place with gauze ties looped through holes cut in the four corners of the mask. See the Plan of Nursing Care 56-1 for more information.
Pruritus GENERAL ITCHING
cr, oint, gel
Pruritus (ie, itching) is one of the most common symptoms of patients with dermatologic disorders. Itch receptors are unmyelinated, penicillate (ie, brushlike) nerve endings that are found exclusively in the skin, mucous membranes, and cornea. Although pruritus is usually caused by primary skin disease with resultant rash or lesions, it may occur without a rash or lesion. This is referred to as essential pruritus, which generally has a rapid onset, may be severe, and interferes with normal daily activities. Pruritus may be the first indication of a systemic internal disease such as diabetes mellitus, blood disorders, or cancer. It may also accompany renal, hepatic, and thyroid diseases (Chart 56-2). Some common oral medications such as aspirin, antibiotics, hormones (ie, estrogens, testosterone, or oral contraceptives), and opioids (ie, morphine or cocaine) may cause pruritus directly or by increasing sensitivity to ultraviolet light. Certain soaps and chemicals, radiation therapy, prickly heat (ie, miliaria), and contact with woolen garments are also associated with pruritus. Pruritus may also be caused by psychological factors, such as excessive stress in family or work situations.
cr, oint, gel
Pathophysiology
cr, solution cr, solution cr, oint cr, oint cr, oint, lot cr, oint, gel cr, oint, gel cr, oint cr, oint
cr, oint
*cr, cream; lot, lotion; oint, ointment; OTC, over the counter
Nursing management for patients who must perform self-care for skin problems, such as applying medications and dressings, focuses mainly on teaching the patient how to wash the affected area and pat it dry, apply medication to the lesion while the skin is moist, cover the area with plastic (eg, Telfa pads, plastic wrap, vinyl gloves, plastic bag) if recommended, and cover it with an elastic bandage, dressing, or paper tape to seal the edges. Dressings that contain or cover a topical corticosteroid should be removed for 12 of every 24 hours to prevent skin thinning (ie, atrophy), striae, and telangiectasia (ie, small, red lesions caused by dilation of blood vessels). Other forms of dressings, such as those used to cover topical medications, include soft cotton cloth and stretchable cotton dressings (eg, Surgitube, TubeGauz) that can be used for fingers, toes, hands, and feet. The hands can be covered with disposable polyethylene or vinyl gloves sealed at the wrists; the feet can be wrapped in plastic bags covered by cotton socks. Gloves and socks that are already impregnated with emollients, making application to the hands and feet more convenient, are also available. When large areas of the body must be covered, cotton cloth topped by an expandable stockinette can be used. Disposable diapers or cloths folded in diaper fashion are useful for dressing the groin and the
Scratching the itchy area causes the inflamed cells and nerve endings to release histamine, which produces more pruritus, generating a vicious itch–scratch cycle. If the patient responds to an itch by scratching, the integrity of the skin may be altered, and excoriation, redness, raised areas (ie, wheals), infection, or changes in pigmentation may result. Pruritus usually is more severe at night and is less frequently reported during waking hours, probably because the person is distracted by daily activities. At night, when there are few distractions, the slightest pruritus cannot be easily ignored. Severe itching is debilitating. Gerontologic Considerations Pruritus occurs frequently in elderly people as a result of dry skin. Elderly people are also more likely to have a systemic illness that triggers pruritus, are at higher risk for occult malignancy, and are more likely to be on multiple medications than is the younger population. All of these factors increase the incidence of pruritus.
Medical Management A thorough history and physical examination usually provide clues to the underlying cause of the pruritus, such as hay fever, allergy, recent administration of a new medication, or a change of cosmetics or soaps. After the cause has been identified, treatment of the condition should relieve the pruritus. Signs of infection and environmental clues, such as warm, dry air or irritating bed linens, should be identified. In general, washing with soap and hot water (text continues on page 1664)
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Plan of Nursing Care Patients With Dermatoses (Abnormal Skin Conditions) Nursing Interventions
Rationale
Expected Outcomes
Nursing Diagnosis: Impaired skin integrity related to changes in the barrier function of the skin Goal: Maintenance of skin integrity 1. Protect healthy skin from maceration (excessive hydration of stratum corneum) when applying wet dressings. 2. Remove moisture from skin by blotting gently and avoiding friction. 3. Guard carefully against risks of thermal injuries from excessively hot wet dressings and from subtle heat injuries (heating pads, radiators). 4. Advise patient to use sunscreening agents.
1. Maceration of healthy skin can cause skin breakdown and extension of the primary condition. 2. Friction and maceration play a major role in some skin diseases. 3. Patients with dermatoses may have decreased sensitivity to heat.
• • • • • •
Maintains skin integrity Absence of maceration No signs of thermal injury Absence of infection Applies prescribed topical medication Takes prescribed medication on schedule
4. Many cosmetic problems and virtually all cutaneous malignancies can be attributed to chronic skin damage.
Nursing Diagnosis: Acute pain and itching related to skin lesions Goal: Relief of discomfort 1. Examine area of involvement. a. Attempt to discover cause of discomfort. b. Record observations in detail, using descriptive terminology.
c. Anticipate possible allergic reaction; obtain a medication history. 2. Control environmental and physical factors. a. Keep humidity about 60%; use a humidifier. b. Maintain a cool environment. c. Use mild soap for sensitive skin (Dove, Cataphyl, Aveeno). d. Remove excess clothing or bedding. e. Wash bed linens and clothing with mild fragrance-free soap. f. Stop repeated exposures to detergents, cleansers, and solvents. 3. Use skin care measures to maintain skin integrity and promote comfort. a. Provide tepid cooling baths or cool dressings for itching. b. Treat dryness (xerosis) as prescribed.
c. Apply skin lotion or cream immediately after bathing.
1. Understanding the extent and characteristics of the skin involved helps in planning interventions. a. Helps to identify appropriate comfort measures. b. An accurate description of a cutaneous lesion is necessary for diagnosis and treatment. Many skin conditions appear similar but have different etiologies. Cutaneous inflammatory response may be muted in elderly patients. c. A generalized rash, particularly of sudden onset, may indicate a medication allergy. 2. Itching is aggravated by heat, chemicals, and physical irritants. a. At low humidity, the skin loses water.
• Achieves relief of discomfort • Verbalizes that itching has been relieved • Demonstrates absence of skin excoriation from scratching
• Complies with prescribed treatment • Keeps skin hydrated and lubricated • Demonstrates intact skin; skin regaining healthy appearance
b. Coolness deters itching. c. These contain no detergents, dyes, fragrances, or hardening agents. d. Promotes cool environment. e. Strong soaps and laundry additives can cause skin irritation. f. Any substance that removes water, lipids, or protein from the epidermis alters the skin’s barrier function. 3. The skin is an important barrier that must be maintained intact to function properly. a. Gradual evaporation of water from dressings cools the skin and relieves pruritus. b. Dry skin can produce areas of dermatitis with redness, itching, scaling, and, in more severe forms, swelling, blistering, cracking, and weeping. c. Effective hydration of the stratum corneum prevents compromise of the barrier layer of the skin. (continued)
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Plan of Nursing Care Patients With Dermatoses (Abnormal Skin Conditions) (Continued) Nursing Interventions d. Keep nails trimmed. e. Apply prescribed topical therapy. f. Help the patient accept possibly prolonged treatment. g. Advise the patient to refrain from using salves or lotions that are commercially available.
Rationale
Expected Outcomes
d. Trimming decreases skin damage from scratching. e. This helps to relieve symptoms. f. Effective coping measures usually promote comfort. g. The patient’s problem may be aggravated by self-medication.
Nursing Diagnosis: Disturbed sleep pattern related to pruritus Goal: Achievement of restful sleep 1. Prevent and treat dry skin. a. Advise patient to keep bedroom well ventilated and humidified. b. Keep skin moisturized. c. Bathe/shower only as necessary if skin is excessively dry. Use no soap or only mild soap. Apply skin lotion/cream immediately after bathing while skin is damp. 2. Advise patient of the following measures that may be helpful in promoting sleep: a. Keep a regular schedule for sleeping. Go to bed at the same time; get up at the same time. b. Avoid caffeinated drinks in the evening. c. Exercise regularly, particularly in late afternoon. d. Use a bedtime routine or ritual. e. Use an antihistamine at bedtime if prescribed.
1. Nocturnal pruritus interferes with normal sleep. a. Dry air will make skin feel itchy. A comfortable environment promotes relaxation. b. This prevents water loss. Dry, itchy skin can usually be controlled but not cured. c. These measures preserve skin moisture.
• Achieves restful sleep • Reports relief of itching • Maintains appropriate environmental conditions
• Avoids caffeine in late afternoon and evening
• Identifies measures to promote sleep • Experiences satisfactory rest/sleep pattern
a. Regularity of sleep schedule is important in maintaining sleep. b. Caffeine has peak effect 2–4 hours after being consumed. c. Exercise at this time appears to have beneficial sleep effect. d. This eases transition from wakefulness to sleep. e. Antihistamines decrease itching and promote sleep.
Nursing Diagnosis: Disturbed body image related to unsightly skin appearance Goal: Development of increasing self-acceptance 1. Assess patient for disturbance of selfimage (avoidance of eye contact, selfnegating verbalizations, expression of disgust about skin condition). 2. Identify psychosocial stage of development. 3. Provide opportunity for expression. Listen (in an open, nonjudgmental way) to expressions of grief/anxiety about changes in body image.
1. Disturbance of body image may accompany any disease or condition that is apparent to the patient. An impression of one’s own body has an effect on selfconcept. 2. There is a relationship between development stage, self-image, and the patient’s reaction to and understanding of skin condition. 3. The patient needs the experience of being heard and understood.
• Develops increasing acceptance of own body
• Follows through and participates in self• • • • •
care measures Reports feeling in control of situation Gives self positive reinforcement Verbalizes a more healthful self-regard Appears less self-conscious; is not afraid to socialize and be seen by others Uses concealing and highlighting techniques to enhance appearance
(continued)
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Rationale
4. Assess the patient’s concerns and fears. Assist anxious patient to develop insight and identify and cope with problems.
4. This gives health care personnel opportunity to neutralize undue anxiety and restore reality to the situation. Fear is destructive to adaptation. 5. A positive approach and suggestions about cosmetic techniques are often helpful in promoting self-acceptance and socialization.
5. Support patient’s efforts to improve body image (participation in skin treatments; grooming), develop self-acceptance, socialize with others, and use cosmetics to conceal disfigurement.
Expected Outcomes
Nursing Diagnosis: Deficient knowledge about skin care and methods of treating skin ailment Goal: Understanding of skin care 1. Determine what the patient knows (understands and misunderstands) about the condition. 2. Keep the patient informed; correct misconceptions/misinformation. 3. Demonstrate application of prescribed therapy (wet compresses; topical medication). 4. Advise the patient to keep skin moist and flexible with hydration and application of skin cream and lotion. 5. Encourage the patient to attain a healthy nutritional status.
1. Provides baseline data for developing the teaching plan.
• Acquires understanding of skin care • Follows treatment as prescribed and can
2. Patients need to have a sense that there is something they can do. Most patients benefit from explanations and reassurance. 3. Allows patient the opportunity to observe the correct way to perform therapies.
• Carries out prescribed baths, soaks, wet
verbalize rationale for measures taken dressings
• Uses topical medication appropriately • Understands importance of nutrition to skin health
4. The stratum corneum needs water to stay flexible. Application of skin cream or lotion to damp skin prevents dry, rough, cracked, and scaly skin. 5. The appearance of the skin reflects a person’s general health. Changes may signal abnormal nutrition.
Collaborative Problems: Infection Goal: Absence of complications 1. Have a high index of suspicion for an infection in patients with compromised immune systems. 2. Instruct the patient clearly and in detail about the therapeutic regimen.
3. Apply intermittent wet dressings as prescribed to reduce intensity of inflammation.
4. Provide tub baths and soaks as prescribed. 5. Administer prescribed antimicrobial agents.
1. Any condition that compromises the immune status increases the risk of cutaneous infection. 2. Effective patient education is dependent on the interpersonal skills of the health professionals and on giving clear instructions reinforced through written instructions. 3. A wet dressing produces evaporative cooling, causing constriction of superficial cutaneous vessels and thereby decreasing erythema and serum production. Wet dressings help in débridement of vesicles and crusts and control inflammatory processes. 4. Loosens exudates and scales.
• Remains free of infection • Describes skin care measures that promote cleanliness and prevent skin breakdown
• Identifies signs and symptoms of infection to report
• Identifies adverse effects of medications •
that should be reported to health care personnel Participates in skin care measures (eg, dressing changes, soaks)
5. Kills or prevents the growth of the infectious organism.
(continued)
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Plan of Nursing Care Patients With Dermatoses (Abnormal Skin Conditions) (Continued) Nursing Interventions
Rationale
6. Use topical medications containing corticosteroids as prescribed and as indicated. a. Observe lesion periodically for changes in response to therapy. b. Instruct the patient about possible adverse effects of long-term use of fluorinated topical corticosteroids. 7. Advise patient to stop using any skin agent that makes the problem worse.
6. Corticosteroids have an anti-inflammatory action, resulting in part from their ability to induce vasoconstriction of the small vessels in the upper dermis. Extensive prolonged use of topical corticosteroids can lead to antiproliferative effects on epidermal cells (loss of hair in area used; thinning of the skin). 7. A contact dermatitis or allergic reaction may develop from any ingredient in the medication.
is avoided. Bath oils (eg, Lubath, Alpha-Keri) containing a surfactant that makes the oil mix with bath water may be sufficient for cleaning. However, an elderly patient or a patient with unsteady balance should avoid adding oil because it increases the danger of slipping in the bathtub. A warm bath with a mild soap followed by application of a bland emollient to moist skin can control xerosis (ie, dry skin). Applying a cold compress, ice cube, or cool agents that contain menthol and camphor (which constrict blood vessels) may also help relieve pruritus. PHARMACOLOGIC THERAPY Topical corticosteroids may be beneficial as anti-inflammatory agents to decrease itching. Oral antihistamines are even more effective because they can overcome the effects of histamine release from damaged mast cells. An antihistamine, such as diphenhydramine (Benadryl) or hydroxyzine (Atarax), prescribed in a sedative dose at bedtime is effective in producing a restful and comfortable sleep. Nonsedating antihistamine medications such
Chart 56-2
Systemic Disorders Associated With Generalized Pruritus
Chronic renal disease Obstructive biliary disease (primary biliary cirrhosis, extrahepatic biliary obstruction, drug-induced cholestasis) Endocrine disease (thyrotoxicosis, hypothyroidism, diabetes mellitus) Psychiatric disorders (emotional stress, anxiety, neurosis, phobias) Malignancies (polycythemia vera, Hodgkin’s disease, lymphoma, leukemia, multiple myeloma, mycosis fungoides, and cancers of the lung, breast, central nervous system, and gastrointestinal tract) Neurologic disorders (multiple sclerosis, brain abscess, brain tumor) Infestations (scabies, lice, other insects) Pruritus of pregnancy (pruritic urticarial papules of pregnancy [PUPP], cholestasis of pregnancy, pemphigoid of pregnancy) Folliculitis (bacterial, candidiasis, dermatophyte) Skin conditions (seborrheic dermatitis, folliculitis, iron deficiency anemia, atopic dermatitis)
Expected Outcomes
as fexofenadine (Allegra) should be used to relieve daytime pruritus. Tricyclic antidepressants, such as doxepin (Sinequan), may be prescribed for pruritus of neuropsychogenic origin. If pruritus continues, further investigation of a systemic problem is advised.
Nursing Management The nurse reinforces the reasons for the prescribed therapeutic regimen and counsels the patient on specific points of care. If baths have been prescribed, the patient is reminded to use tepid (not hot) water and to shake off the excess water and blot between intertriginous areas (ie, body folds) with a towel. Rubbing vigorously with the towel is avoided because this overstimulates the skin and causes more itching. It also removes water from the stratum corneum. Immediately after bathing, the skin should be lubricated with an emollient to trap moisture. The patient is instructed to avoid situations that cause vasodilation (ie, expansion of the blood vessels). Examples include exposure to an overly warm environment and ingestion of alcohol or hot foods and liquids. All can induce or intensify itching. Using a humidifier is helpful if environmental air is dry. Activities that result in perspiration should be limited because perspiration may irritate and promote pruritus. If the patient is troubled at night with itching that interferes with sleep, the nurse can advise wearing cotton clothing next to the skin rather than synthetic materials. The room should be kept cool and humidified. Vigorous scratching should be avoided, and nails kept trimmed to prevent skin damage and infection. When the underlying cause of pruritus is unknown and further testing is required, the nurse explains each test and the expected outcome.
PERINEAL AND PERIANAL ITCHING Pruritus of the genital and anal regions may be caused by small particles of fecal material lodged in the perianal crevices or attached to anal hairs or by perianal skin damage caused by scratching, moisture, and decreased skin resistance as a result of corticosteroid or antibiotic therapy. Other possible causes of perianal itching include local irritants such as scabies and lice, local lesions such as hemorrhoids, fungal or yeast infections, and pinworm infestation. Conditions such as diabetes mellitus, anemia, hyperthyroidism, and pregnancy may also result in pruritus. Occasionally, no cause can be identified.
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Management
Management
The patient is instructed to follow proper hygiene measures and to discontinue home and over-the-counter remedies. The perineal or anal area should be rinsed with lukewarm water and blotted dry with cotton balls. Premoistened tissues may be used after defecation. Cornstarch can be applied in the skinfold areas to absorb perspiration. As part of health teaching, the nurse instructs the patient to avoid bathing in water that is too hot and to avoid using bubble baths, sodium bicarbonate, and detergent soaps, all of which aggravate dryness. To keep the perineal or perianal skin area as dry as possible, patients should avoid wearing underwear made of synthetic fabrics. Local anesthetic agents should not be used because of possible allergic effects. The patient should also avoid vasodilating agents or stimulants (eg, alcohol, caffeine) and mechanical irritants such as rough or woolen clothing. A diet that includes adequate fiber may help maintain soft stools and prevent minor trauma to the anal mucosa.
Management is difficult. Hot compresses and oral antibiotics are used frequently. Isotretinoin (Accutane) or etretinate can be tried; careful monitoring for side effects is important. Incision and drainage of large suppurating areas with gauze packs inserted to facilitate drainage is often necessary. Rarely, the entire area is excised, removing the scar tissue and any infection. This surgery is drastic and attempted only as a last resort (Hall, 2000).
Secretory Disorders
SEBORRHEIC DERMATOSES Seborrhea is excessive production of sebum (ie, secretion of sebaceous glands) in areas where sebaceous glands are normally found in large numbers, such as the face, scalp, eyebrows, eyelids, sides of the nose and upper lip, malar regions (ie, cheeks), ears, axillae, under the breasts, groin, and gluteal crease of the buttocks. Seborrheic dermatitis is a chronic inflammatory disease of the skin with a predilection for areas that are well supplied with sebaceous glands or lie between skin folds, where the bacteria count is high.
Clinical Manifestations
The main secretory function of the skin is performed by the sweat glands, which help to regulate body temperature. These glands excrete perspiration that evaporates, thereby cooling the body. The sweat glands are located in various parts of the body and respond to different stimuli. Those on the trunk generally respond to thermal stimulation; those on the palms and soles respond to nervous stimulation; and those in the axillae and on the forehead respond to both kinds of stimulation. Normal perspiration has no odor. Body odor is produced by the increase in bacteria on the skin and the interaction of bacterial waste products with the chemicals of perspiration. As a rule, moist skin is warm, and dry skin is cool, but this is not always true. It is not unusual to observe warm, dry skin in a dehydrated patient and very hot, dry skin in some febrile states. Normally, sweat can be controlled with the use of antiperspirants and deodorants. Most antiperspirants are aluminum salts that block the opening to the sweat duct. Pure deodorants inhibit bacterial growth and block the metabolism of sweat; they have no antiperspirant effect. Fragrance-free deodorants are available for those with sensitive skin (Odom et al., 2000).
Two forms of seborrheic dermatoses can occur, an oily form and a dry form. Either form may start in childhood and continue throughout life. The oily form appears moist or greasy. There may be patches of sallow, greasy skin, with or without scaling, and slight erythema (ie, redness), predominantly on the forehead, nasolabial fold, beard area, scalp, and between adjacent skin surfaces in the regions of the axillae, groin, and breasts. Small pustules or papulopustules resembling acne may appear on the trunk. The dry form, consisting of flaky desquamation of the scalp with a profuse amount of fine, powdery scales, is commonly called dandruff. The mild forms of the disease are asymptomatic. When scaling occurs, it is often accompanied by pruritus, which may lead to scratching and secondary infections and excoriation. Seborrheic dermatitis has a genetic predisposition. Hormones, nutritional status, infection, and emotional stress influence its course. The remissions and exacerbations of this condition should be explained to the patient. If a person has not previously been diagnosed with this condition and suddenly appears with a severe outbreak, a complete history and physical examination should be considered.
HYDRADENITIS SUPPURATIVA
Medical Management
A condition called hydradenitis suppurativa can occur in certain individuals. The cause is unknown.
Because there is no known cure for seborrhea, the objective of therapy is to control the disorder and allow the skin to repair itself. Seborrheic dermatitis of the body and face may respond to a topically applied corticosteroid cream, which allays the secondary inflammatory response. However, this medication should be used with caution near the eyelids, because it can induce glaucoma and cataracts in predisposed patients. Patients with seborrheic dermatitis may develop a secondary candidal (yeast) infection in body creases or folds. To avoid this, patients should be advised to ensure maximum aeration of the skin and to clean carefully areas where there are creases or folds in the skin. Patients with persistent candidiasis should be evaluated for diabetes. The mainstay of dandruff treatment is proper, frequent shampooing (daily or at least three times weekly) with medicated shampoos. Two or three different types of shampoo should be used in rotation to prevent the seborrhea from becoming resistant to a particular shampoo. The shampoo is left on at least 5 to 10 minutes. As the condition of the scalp improves, the treatment
Pathophysiology Abnormal blockage of the sweat glands causes recurring inflammation, nodules, and draining sinus tracts. Eventually, hypertrophic bands of scar tissue form in the area of the sweat glands.
Clinical Manifestations The condition occurs more frequently in the axilla but also appears in inguinal folds, on the mons pubis, and around the buttocks. The patients can be extremely uncomfortable with multiple suppurative lesions within a small area. This condition does not appear before puberty and does appear to have a genetic basis.
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can be less frequent. Antiseborrheic shampoos include those containing selenium sulfide suspension, zinc pyrithione, salicylic acid or sulfur compounds, and tar shampoo that contains sulfur or salicylic acid.
Nursing Management A person with seborrheic dermatitis is advised to avoid external irritants, excessive heat, and perspiration; rubbing and scratching prolong the disorder. To avoid secondary infection, the patient should air the skin and keep skin folds clean and dry. Instructions for using medicated shampoos are reinforced for those with dandruff that requires treatment. Frequent shampooing is contrary to some cultural practices; the nurse should be sensitive to these differences when teaching the patient about home care. The patient is cautioned that seborrheic dermatitis is a chronic problem that tends to reappear. The goal is to keep it under control. Patients need to be encouraged to adhere to the treatment program. Those who become discouraged and disheartened by the effect on body image should be treated with sensitivity and an awareness of their need to express their feelings.
ACNE VULGARIS Acne vulgaris is a common follicular disorder affecting susceptible hair follicles, most commonly found on the face, neck, and upper trunk. It is characterized by comedones (ie, primary acne lesions), both closed and open, and by papules, pustules, nodules, and cysts. Acne is the most commonly encountered skin condition in adolescents and young adults between ages 12 and 35. Both genders are affected equally, although onset is slightly earlier for girls. This may be because girls reach puberty at a younger age than boys. Acne becomes more marked at puberty and during adolescence because the endocrine glands that influence the secretions of the sebaceous glands are functioning at peak activity. Acne appears to stem from an interplay of genetic, hormonal, and bacterial factors. In most cases, there is a family history of acne.
Pathophysiology During childhood, the sebaceous glands are small and virtually nonfunctioning. These glands are under endocrine control, especially by the androgens. During puberty, androgens stimulate the sebaceous glands, causing them to enlarge and secrete a natural oil, sebum, which rises to the top of the hair follicle and flows out onto the skin surface. In adolescents who develop acne, androgenic stimulation produces a heightened response in the sebaceous glands so that acne occurs when accumulated sebum plugs the pilosebaceous ducts. This accumulated material forms comedones.
Clinical Manifestations The primary lesions of acne are comedones. Closed comedones (ie, whiteheads) are obstructive lesions formed from impacted lipids or oils and keratin that plug the dilated follicle. They are small, whitish papules with minute follicular openings that generally cannot be seen. These closed comedones may evolve into open comedones, in which the contents of the ducts are in open communication with the external environment. The color of open comedones (ie, blackheads) results not from dirt, but from an accumulation of lipid, bacterial, and epithelial debris.
Although the exact cause is unknown, some closed comedones may rupture, resulting in an inflammatory reaction caused by leakage of follicular contents (eg, sebum, keratin, bacteria) into the dermis. This inflammatory response may result from the action of certain skin bacteria, such as Propionibacterium acnes, that live in the hair follicles and break down the triglycerides of the sebum into free fatty acids and glycerin. The resultant inflammation is seen clinically as erythematous papules, inflammatory pustules, and inflammatory cysts. Mild papules and cysts drain and heal on their own without treatment. Deeper papules and cysts may result in scarring of the skin. Acne is usually graded as mild, moderate, or severe based on the number and type of lesions (eg, comedones, papules, pustules, cysts).
Assessment and Diagnostic Findings The diagnosis of acne is based on the history and physical examination, evidence of lesions characteristic of acne, and age. Acne does not occur until puberty. The presence of the typical comedones (ie, whiteheads and blackheads) along with excessively oily skin is characteristic. Oiliness is more prominent in the midfacial area; other parts of the face may appear dry. When there are numerous lesions, some of which are open, the person may exude a distinct sebaceous odor. Women may report a history of flare-ups a few days before menses. Biopsy of lesions is seldom necessary for a definitive diagnosis.
Medical Management The goals of management are to reduce bacterial colonies, decrease sebaceous gland activity, prevent the follicles from becoming plugged, reduce inflammation, combat secondary infection, minimize scarring, and eliminate factors that predispose the person to acne. The therapeutic regimen depends on the type of lesion (eg, comedonal, papular, pustular, cystic). There is no predictable cure for the disease, but combinations of therapies are available that can effectively control its activity. Topical treatment may be all that is needed to treat mild to moderate lesions and superficial inflammatory lesions (ie, papular or pustular). NUTRITION AND HYGIENE THERAPY Although food restrictions have been recommended from time to time in treating acne, diet is not believed to play a major role in therapy. However, the elimination of a specific food or food product associated with a flare-up of acne, such as chocolate, cola, fried foods, or milk products, should be promoted. Maintenance of good nutrition equips the immune system for effective action against bacteria and infection. For mild cases of acne, washing twice each day with a cleansing soap may be all that is required. These soaps can remove the excessive skin oil and the comedo in most cases. Providing positive reassurance, listening attentively, and being sensitive to the feelings of the patient with acne are essential contributors to the patient’s psychological well-being and understanding of the disease and treatment plan. Over-the-counter acne medications contain salicylic acid and benzoyl peroxide, both of which are very effective at removing the sebaceous follicular plugs. However, the skin of some people is sensitive to these products, which can cause irritation or excessive dryness, especially when used with some prescribed topical medications. The patient should be instructed to discontinue their use if severe irritation occurs. Oil-free cosmetics and creams should be chosen. These products are usually designated as useful
Chapter 56 for acne-prone skin. The duration of treatment depends on the extent and severity of the acne. In severe cases, treatment may extend over years. TOPICAL PHARMACOLOGIC THERAPY Benzoyl Peroxide. Benzoyl peroxide preparations are widely used because they produce a rapid and sustained reduction of inflammatory lesions. They depress sebum production and promote breakdown of comedo plugs. They also produce an antibacterial effect by suppressing P. acnes. Initially, benzoyl peroxide causes redness and scaling, but the skin usually adjusts quickly to its use. Typically, the patient applies a gel of benzoyl peroxide once daily. In many instances, this is the only treatment needed. Benzoyl peroxide, benzoyl erythromycin, and benzoyl sulfur combinations are available over the counter and by prescription. Vitamin A acid (tretinoin) applied topically is used to clear the keratin plugs from the pilosebaceous ducts. Vitamin A acid speeds the cellular turnover, forces out the comedones, and prevents new comedones. The patient should be informed that symptoms may worsen during early weeks of therapy because inflammation may occur during the process. Erythema and peeling also frequently result. Improvement may take 8 to 12 weeks. Some patients cannot tolerate this therapy. The patient is cautioned against sun exposure while using this topical medication because it may cause an exaggerated sunburn. Package insert directions should be followed carefully. Topical Antibiotics. Topical antibiotic treatment for acne is common. Topical antibiotics suppress the growth of P. acnes; reduce superficial free fatty acid levels; decrease comedones, papules, and pustules; and produce no systemic side effects. Common topical preparations include tetracycline, clindamycin, and erythromycin. SYSTEMIC PHARMACOLOGIC THERAPY Antibiotics. Oral antibiotics, such as tetracycline, doxycycline, and minocycline, administered in small doses over a long period are very effective in treating moderate and severe acne, especially when the acne is inflammatory and results in pustules, abscesses, and scarring. Therapy may continue for months to years. The tetracycline family of antibiotics is contraindicated in children younger than age 12 and in pregnant women. Although these medications are considered safe for long-term use in most cases, administration during pregnancy can affect the development of teeth, causing enamel hypoplasia and permanent discoloration of teeth in infants. Side effects of tetracyclines include photosensitivity, nausea, diarrhea, cutaneous infection in either gender, and vaginitis in women. In some women, broad-spectrum antibiotics may suppress normal vaginal bacteria and predispose the patient to candidiasis, a fungal infection. Oral Retinoids. Synthetic vitamin A compounds (ie, retinoids) are used with dramatic results in patients with nodular cystic acne unresponsive to conventional therapy. One compound is isotretinoin (Accutane). Isotretinoin is also used for active inflammatory papular pustular acne that has a tendency to scar. Isotretinoin reduces sebaceous gland size and inhibits sebum production. It also causes the epidermis to shed (ie, epidermal desquamation), thereby unseating and expelling existing comedones. The most common side effect, experienced by almost all patients, is cheilitis (ie, inflammation of the lips). Dry and chafed skin and mucous membranes are frequent side effects. These
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changes are reversible with the withdrawal of the medication. Most important, isotretinoin, like other vitamin A metabolites, is teratogenic in humans, meaning that it can have an adverse effect on a fetus, causing central nervous system and cardiovascular defects and structural abnormalities of the face. Contraceptive measures for women of childbearing age are mandatory during treatment and for about 4 to 8 weeks thereafter. To avoid additive toxic effects, patients are cautioned not to take vitamin A supplements while taking isotretinoin (Odom et al., 2000). Hormone Therapy. Estrogen therapy (including progesterone– estrogen preparations) suppresses sebum production and reduces skin oiliness. It is usually reserved for young women when the acne begins somewhat later than usual and tends to flare up at certain times in the menstrual cycle. Estrogen in the form of estrogen-dominant oral contraceptive compounds may be administered on a prescribed cyclic regimen. Estrogen is not administered to male patients because of undesirable side effects such as enlargement of the breasts and decrease in body hair. SURGICAL MANAGEMENT Surgical treatment of acne consists of comedo extraction, injections of corticosteroids into the inflamed lesions, and incision and drainage of large, fluctuant (ie, moving in palpable waves), nodular cystic lesions. Cryosurgery (ie, freezing with liquid nitrogen) may be used for nodular and cystic forms of acne. Patients with deep scars may be treated with deep abrasive therapy (ie, dermabrasion), in which the epidermis and some superficial dermis are removed down to the level of the scars. Comedones may be removed with a comedo extractor. The site is first cleaned with alcohol. The opening of the extractor is then placed over the lesion, and direct pressure is applied to cause extrusion of the plug through the extractor. Removal of comedones leaves erythema, which may take several weeks to subside. Recurrence of comedones after extraction is common because of the continuing activity of the pilosebaceous glands. Table 56-5 summarizes the treatment modalities for acne vulgaris.
Nursing Management Nursing care of patients with acne consists largely of monitoring and managing potential complications of skin treatments. Major nursing activities include patient education, particularly in proper skin care techniques, and managing potential problems related to the skin disorder or therapy. PREVENTING SCARRING Prevention of scarring is the ultimate goal of therapy. The chance of scarring increases as the grade of acne increases. Grades III and IV (25 to more than 50 comedones, papules, or pustules) usually require longer-term therapy with systemic antibiotics or isotretinoin. Patients should be warned that discontinuing these medications can exacerbate acne, lead to more flare-ups, and increase the chance of deep scarring. Moreover, manipulation of the comedones, papules, and pustules increases the potential for scarring. When acne surgery is prescribed to extract deep-seated comedones or inflamed lesions or to incise and drain cystic lesions, the intervention itself may result in further scarring. Dermabrasion, which levels existing scar tissue, can also increase scar formation. Hyperpigmentation or hypopigmentation also may affect the tis-
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Table 56-5
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• Commonly Prescribed Treatments of Acne Vulgaris
TYPE OF THERAPY
PRESCRIBED TREATMENT AGENT
Topical
benzoyl peroxide wash, gel benzoyl peroxide and erythromycin (Benzamycin gel) benzoyl peroxide and sulfur (Benzulfoid cream) resorcinol (as ingredient in other preparations) salicylic acid (as ingredient in other preparations) sulfur (as ingredient in other preparations) tretinoin (Retin A, Avita) other comedogenics (adapalene [Differen], azelaic acid [Azelex], tazorotene [Tazorac]) topical antibiotics oral antibiotics (erythromycin, tetracycline, doxycycline, minocin, penicillins) isotretinoin (Accutane) hormones: corticosteroids high dose for anti-inflammatory action low dose to suppress androgenic action intralesional for anti-inflammatory action antiandrogens oral contraceptives (women only) extraction of comedo contents drainage of pustules and cysts excision of sinus tracts and cysts intralesional corticosteroids for antiinflammatory action cryotherapy dermabrasion for scars laser resurfacing of scars
Systemic
Surgical
Treatments listed are common but do not include all available forms of therapy.
sue involved. The patient should be informed of these potential outcomes before choosing surgical intervention for acne. PREVENTING INFECTION Female patients receiving long-term antibiotic therapy with tetracycline should be advised to watch for and report signs and symptoms of oral or vaginal candidiasis, a yeastlike fungal infection. PROMOTING HOME AND COMMUNITY-BASED CARE Teaching Patients Self-Care. In addition to receiving instructions for taking prescribed medications, patients are instructed to wash the face and other affected areas with mild soap and water twice each day to remove surface oils and prevent obstruction of the oil glands. They are cautioned to avoid scrubbing the face; acne is not caused by dirt and cannot be washed away. Mild abrasive soaps and drying agents are prescribed to eliminate the oily feeling that troubles many patients. At the same time, patients are cautioned to avoid excessive abrasion because it makes acne worse. Excessive abrasion causes minute scratches on the skin surface and increases possible bacterial contamination. Soap itself can irritate the skin. All forms of friction and trauma are avoided, including propping the hands against the face, rubbing the face, and wearing
tight collars and helmets. Patients are instructed to avoid manipulation of pimples or blackheads. Squeezing merely worsens the problem, because a portion of the blackhead is pushed down into the skin, which may cause the follicle to rupture. Because cosmetics, shaving creams, and lotions can aggravate acne, these substances are best avoided unless the patient is advised otherwise. There is no evidence that a particular food can cause or aggravate acne. In general, eating a nutritious diet helps the body maintain a strong immune system.
Bacterial Infections: Pyodermas Also called pyodermas, pus-forming bacterial infections of the skin may be primary or secondary. Primary skin infections originate in previously normal-appearing skin and are usually caused by a single organism. Secondary skin infections arise from a preexisting skin disorder or from disruption of the skin integrity from injury or surgery. In either case, several microorganisms may be implicated (eg, Staphylococcus aureus, group A streptococci). The most common primary bacterial skin infections are impetigo and folliculitis. Folliculitis may lead to furuncles or carbuncles.
IMPETIGO Impetigo is a superficial infection of the skin caused by staphylococci, streptococci, or multiple bacteria. Bullous impetigo, a more deep-seated infection of the skin caused by S. aureus, is characterized by the formation of bullae (ie, large, fluid-filled blisters) from original vesicles. The bullae rupture, leaving raw, red areas. The exposed areas of the body, face, hands, neck, and extremities are most frequently involved. Impetigo is contagious and may spread to other parts of the patient’s skin or to other members of the family who touch the patient or use towels or combs that are soiled with the exudate of the lesions. Although impetigo is seen at all ages, it is particularly common among children living in poor hygienic conditions. It often follows pediculosis capitis (head lice), scabies (itch mites), herpes simplex, insect bites, poison ivy, or eczema. Chronic health problems, poor hygiene, and malnutrition may predispose an adult to impetigo. Some people have been identified as asymptomatic carriers of S. aureus, usually in the nasal passages.
Clinical Manifestations The lesions begin as small, red macules, which quickly become discrete, thin-walled vesicles that soon rupture and become covered with a loosely adherent honey-yellow crust (Fig. 56-1). These crusts are easily removed to reveal smooth, red, moist surfaces on which new crusts soon develop. If the scalp is involved, the hair is matted, which distinguishes the condition from ringworm.
Medical Management Systemic antibiotic therapy is the usual treatment. It reduces contagious spread, treats deep infection, and prevents acute glomerulonephritis (ie, kidney infection), which may occur as an aftermath of streptococcal skin diseases. In nonbullous impetigo, benzathine penicillin or oral penicillin may be prescribed. Bullous impetigo is treated with a penicillinase-resistant penicillin (eg, cloxacillin,
Chapter 56
FIGURE 56-1
Impetigo of the nostril.
dicloxacillin). In penicillin-allergic patients, erythromycin is an effective alternative. Topical antibacterial therapy (eg, mupirocin) may be prescribed when the disease is limited to a small area. However, topical therapy requires that the medication be applied to the lesions several times daily for a week. The treatment regimen may be impossible for some patients or their caregivers to follow. Topical antibiotics generally are not as effective as systemic therapy in eradicating or preventing the spread of streptococci from the respiratory tract, thereby increasing the risk for developing glomerulonephritis. When topical therapy is prescribed, lesions are soaked or washed with soap solution to remove the central site of bacterial growth, giving the topical antibiotic an opportunity to reach the infected site. After the crusts are removed, a topical medication (eg, Polysporin, bacitracin) may be applied. Gloves are worn when providing patient care. An antiseptic solution, such as povidone-iodine (Betadine) may be used to clean the skin, reduce bacterial content in the infected area, and prevent spread.
Nursing Management The nurse instructs the patient and family members to bathe at least once daily with bactericidal soap. Cleanliness and good hygiene practices help prevent the spread of the lesions from one skin area to another and from one person to another. Each person should have a separate towel and washcloth. Because impetigo is a contagious disorder, infected people should avoid contact with other people until the lesions heal.
FOLLICULITIS, FURUNCLES, AND CARBUNCLES Folliculitis is an infection of bacterial or fungal origin that arises within the hair follicles. Lesions may be superficial or deep. Single or multiple papules or pustules appear close to the hair follicles. Folliculitis commonly affects the beard area of men who shave and women’s legs. Other areas include the axillae, trunk, and buttocks. Pseudofolliculitis barbae (ie, shaving bumps) are an inflammatory reaction that occurs predominately on the faces of African American and other curly-haired men as a result of shaving. The sharp ingrowing hairs have a curved root that grows at a more acute angle and pierces the skin, provoking an irritative reaction. The only entirely effective treatment is to avoid shaving. Other treatments include using special lotions or antibiotics or using a hand brush to dislodge the hairs mechanically. If the patient must
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remove facial hair, a depilatory cream or electric razor may be more appropriate than a straight razor. A furuncle (ie, boil) is an acute inflammation arising deep in one or more hair follicles and spreading into the surrounding dermis. It is a deeper form of folliculitis. Furunculosis refers to multiple or recurrent lesions. Furuncles may occur anywhere on the body but are more prevalent in areas subjected to irritation, pressure, friction, and excessive perspiration, such as the back of the neck, the axillae, and the buttocks. A furuncle may start as a small, red, raised, painful pimple. Frequently, the infection progresses and involves the skin and subcutaneous fatty tissue, causing tenderness, pain, and surrounding cellulitis. The area of redness and induration represents an effort of the body to keep the infection localized. The bacteria (usually staphylococci) produce necrosis of the invaded tissue. The characteristic pointing of a boil follows in a few days. When this occurs, the center becomes yellow or black, and the boil is said to have “come to a head.” A carbuncle is an abscess of the skin and subcutaneous tissue that represents an extension of a furuncle that has invaded several follicles and is large and deep seated. It is usually caused by a staphylococcal infection. Carbuncles appear most commonly in areas where the skin is thick and inelastic. The back of the neck and the buttocks are common sites. In carbuncles, the extensive inflammation frequently prevents a complete walling off of the infection; absorption may occur, resulting in high fever, pain, leukocytosis, and even extension of the infection to the bloodstream. Furuncles and carbuncles are more likely to occur in patients with underlying systemic diseases, such as diabetes or hematologic malignancies, and in those receiving immunosuppressive therapy for other diseases. Both are more prevalent in hot climates, especially on skin beneath occlusive clothing.
Medical Management In treating staphylococcal infections, it is important not to rupture or destroy the protective wall of induration that localizes the infection. The boil or pimple should never be squeezed. Follicular disorders, including folliculitis, furuncles, and carbuncles, are usually caused by staphylococci; although if the immune system is impaired, the causative organisms may be gram-negative bacilli. Systemic antibiotic therapy, selected by sensitivity study, is generally indicated. Oral cloxacillin, dicloxacillin, and flucloxacillin are first-line medications. Cephalosporins and erythromycin are also effective. Bed rest is advised for patients who have boils on the perineum or in the anal region, and a course of systemic antibiotic therapy is indicated to prevent the spread of the infection. When the pus has localized and is fluctuant, a small incision with a scalpel can speed resolution by relieving the tension and ensuring direct evacuation of the pus and slough. The patient is instructed to keep the draining lesion covered with a dressing.
Nursing Management Intravenous fluids, fever reduction, and other supportive treatments are indicated for patients who are very ill or suffering with toxicity. Warm, moist compresses increase vascularization and hasten resolution of the furuncle or carbuncle. The surrounding skin may be cleaned gently with antibacterial soap, and an antibacterial ointment may be applied. Soiled dressings are handled according to standard precautions. Nursing personnel should carefully follow isolation precautions to avoid becoming carriers
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of staphylococci. Disposable gloves are worn when caring for these patients.
!
NURSING ALERT Nurses must take special precautions in caring for boils on the face, because the skin area drains directly into the cranial venous sinuses. Sinus thrombosis with fatal pyemia can develop after manipulating a boil in this location. The infection can travel through the sinus tract and penetrate the brain cavity, causing brain abscess.
PROMOTING HOME AND COMMUNITY-BASED CARE Teaching Patients Self-Care. To prevent and control staphylococcal skin infections such as boils and carbuncles, the staphylococcal pathogen must be eliminated from the skin and environment. Efforts must be made to increase the patient’s resistance and provide a hygienic environment. If lesions are actively draining, the mattress and pillow should be covered with plastic material and wiped off with disinfectant daily; the bed linens, towels, and clothing should be laundered after each use; and the patient should use an antibacterial soap and shampoo for an indefinite period, often for several months. Recurrent infection is prevented with the use of prescribed antibiotic therapy (eg, a daily dose of oral clindamycin to be taken continuously for about 3 months). The patient must take the full dose for the time prescribed. The purulent exudate (ie, pus) is a source of reinfection or transmission of infection to caregivers. When the patient has a history of recurrent infections, a carrier state may exist, which should be investigated and treated with an antibacterial cream such as mupirocin.
Viral Skin Infections HERPES ZOSTER Herpes zoster, also called shingles, is an infection caused by the varicella-zoster virus, a member of a group of DNA viruses. The viruses causing chickenpox and herpes zoster are indistinguishable, hence the name varicella-zoster virus. The disease is characterized by a painful vesicular eruption along the area of distribution of the sensory nerves from one or more posterior ganglia. It is assumed that herpes zoster represents a reactivation of latent varicella virus infection and reflects lowered immunity. After a case of chickenpox runs its course, it is thought that the varicellazoster viruses responsible for the outbreak lie dormant inside nerve cells near the brain and spinal cord. Later, when these latent viruses are reactivated, they travel by way of the peripheral nerves to the skin, where the viruses multiply and create a red rash of small, fluid-filled blisters. About 10% of adults get shingles during their lifetimes, usually after age 50 years. There is an increased frequency of herpes zoster infections among patients with weakened immune systems and cancers, especially leukemias and lymphomas (Odom et al., 2000).
patches of grouped vesicles appear on the red and swollen skin. The early vesicles, which contain serum, later may become purulent, rupture, and form crusts. The inflammation is usually unilateral, involving the thoracic, cervical, or cranial nerves in a bandlike configuration. The blisters are usually confined to a narrow region of the face or trunk (Fig. 56-2). The clinical course varies from 1 to 3 weeks. If an ophthalmic nerve is involved, the patient may have eye pain. Inflammation and a rash on the trunk may cause pain with the slightest touch. The healing time varies from 7 to 26 days. Herpes zoster in healthy adults is usually localized and benign. However, in immunosuppressed patients, the disease may be severe and the clinical course acutely disabling.
Medical Management The goals of herpes zoster management are to relieve the pain and to reduce or avoid complications, which include infection, scarring, and postherpetic neuralgia and eye complications. Pain is controlled with analgesics, because adequate pain control during the acute phase helps prevent persistent pain patterns. Systemic corticosteroids may be prescribed for patients older than age 50 years to reduce the incidence and duration of postherpetic neuralgia (ie, persistent pain of the affected nerve after healing). Healing usually occurs sooner in those who have been treated with corticosteroids. Triamcinolone (Aristocort, Kenacort, Kenalog) injected subcutaneously under painful areas is effective as an antiinflammatory agent. There is evidence that infection is arrested if oral antiviral agents such as acyclovir (Zovirax), valacyclovir (Valtrex), or famciclovir (Famvir) are administered within 24 hours of the initial eruption. Intravenous acyclovir, if started early, is effective in significantly reducing the pain and halting the progression of the disease. In older patients, the pain from herpes zoster may persist as postherpetic neuralgia for months after the skin lesions disappear (Hall, 2000). Ophthalmic herpes zoster occurs when an eye is involved. This is considered an ophthalmic emergency, and the patient should be referred to an ophthalmologist immediately to prevent the possible sequelae of keratitis, uveitis, ulceration, and blindness.
Clinical Manifestations The eruption is usually accompanied or preceded by pain, which may radiate over the entire region supplied by the affected nerves. The pain may be burning, lancinating (ie, tearing or sharply cutting), stabbing, or aching. Some patients have no pain, but itching and tenderness may occur over the area. Sometimes, malaise and gastrointestinal disturbances precede the eruption. The
FIGURE 56-2
Herpes zoster (shingles).
Chapter 56 People who have been exposed to varicella (ie, chicken pox) by primary infection or by vaccination are not at risk for infection after exposure to patients with herpes zoster.
Nursing Management The nurse assesses the patient’s discomfort and response to medication and collaborates with the physician to make necessary adjustments to the treatment regimen. The patient is taught how to apply wet dressings or medication to the lesions and to follow proper hand hygiene techniques to avoid spreading the virus. Diversionary activities and relaxation techniques are encouraged to ensure restful sleep and to alleviate discomfort. A caregiver may be required to assist with dressings, particularly if the patient is elderly and unable to apply them. Relatives, neighbors, or a home care nurse may need to help with dressing changes and food preparation for patients who cannot care for themselves or prepare nourishing meals.
HERPES SIMPLEX Herpes simplex is a common skin infection. There are two types of the causative virus, which are identified by viral typing. Generally, herpes simplex type 1 occurs on the mouth and type 2 in the genital area, but both viral types can be found in both locations. About 85% of adults worldwide are seropositive for herpes type 1. The prevalence of type 2 is lower; type 2 usually appears at the onset of sexual activity. Serologic testing shows that many more people are infected than have a history of clinical disease. Herpes simplex is classified as a true primary infection, a nonprimary initial episode, or a recurrent episode. True primary infection is the initial exposure to the virus. A nonprimary initial episode is the initial episode of type 1 or type 2 in a person previously infected with the other type. Recurrent episodes are subsequent episodes of the same viral type.
OROLABIAL HERPES Orolabial herpes, also called fever blisters or cold sores, consists of erythematous-based clusters of grouped vesicles on the lips. A prodrome of tingling or burning with pain may precede the appearance of the vesicles by up to 24 hours. Certain triggers, such as sunlight exposure or increased stress, may cause recurrent episodes. Fewer than 1% of people with primary orolabial herpes infections develop herpetic gingivostomatitis. This complication occurs more in children and young adults. The onset is often accompanied by high fever, regional lymphadenopathy, and generalized malaise. Another complication of orolabial herpes is the development of erythema multiforme, an acute inflammation of the skin and mucous membranes with characteristic lesions that have the appearance of targets.
GENITAL HERPES Genital herpes, or type 2 herpes simplex, manifests with a broad spectrum of clinical signs. Minor infections may produce no symptoms at all; severe primary infections with type 1 can cause systemic flulike illness. Lesions appear as grouped vesicles on an erythematous base initially involving the vagina, rectum, or penis. New lesions can continue to appear for 7 to 14 days. Lesions are symmetric and usually cause regional lymphadenopathy. Fever and flulike symptoms are common. Typical recurrences begin
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with a prodrome of burning, tingling, or itching about 24 hours before the vesicles appear. As the vesicles rupture, erosions and ulcerations begin to appear. Severe infections can cause extensive erosions of the vaginal or anal canal. For further information see Chapter 47.
Assessment and Diagnostic Findings Herpes simplex infections are confirmed in several ways. Generally, the appearance of the skin eruption is strongly suggestive. Viral cultures and rapid assays are available, and the type of test used depends on lesion morphology. Acute vesicular lesions are more likely to react positively to the rapid assay, whereas older, crusted patches are better diagnosed with viral culture. In all cases, it is imperative to obtain enough viral cells for testing, and careful collection methods are therefore important. All crusts should be gently removed or vesicles gently unroofed. A sterile cotton swab premoistened in viral culture preservative is used to swab the base of the vesicle to obtain a specimen for analysis.
Complications Eczema herpeticum is a condition in which patients with eczema contract herpes that spreads throughout the eczematous areas. The same type of spread of herpes can occur in severe seborrhea, scabies, and other chronic skin conditions. Herpes Whitlow is an infection of the pulp of a fingertip with herpes type 1 or 2. There is tenderness and erythema of the lateral fold of the cuticle. Deep-seated vesicles appear within 24 hours. Most cases of neonatal infection with herpes occur during delivery by contact of the infant with the mother’s active ulcerations. Rarely, in mothers who have primary infections during pregnancy, intrauterine neonatal infections occur. Fetal anomalies include skin lesions, microcephaly, encephalitis, and intracerebral calcifications.
Medical Management In many patients, recurrent orolabial herpes represents more of a nuisance than a disease. Because sun exposure is a common trigger, those with recurrent orolabial herpes should use a sunscreen liberally on the lips and face. Topical treatment with drying agents may accelerate healing. In more severe outbreaks or in patients who have identified a trigger, intermittent treatment with 200 mg of acyclovir administered five times each day for 5 days is often started as soon as the earliest symptoms occur. Treatment of genital herpes depends on the severity, the frequency, and the psychological impact of recurrences and on the infectious status of the sexual partner. For people who have mild or rare outbreaks, no treatment may be required. For those who have more severe outbreaks, but for whom outbreaks are still infrequent, intermittent treatment as described for oral lesions can be used. Because intermittent treatment reduces the duration of the infection by only 24 to 36 hours, it should be initiated as early as possible. Patients who have more than six recurrences per year may benefit from suppressive therapy. Use of acyclovir, valacyclovir, or famciclovir suppresses 85% of recurrences, and 20% of patients are free of recurrences during suppressive therapy. Suppressive therapy also reduces viral shedding by almost 95%, making the person less contagious. Treatment with suppressive doses of oral antiviral medications prevents recurrent erythema multiforme.
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Eczema herpeticum is managed with oral or intravenous acyclovir. Management of genital herpes in pregnancy is controversial. Routine prenatal cultures do not predict shedding at the time of delivery. The use of scalp electrodes during delivery should be avoided because they increase the risk for infection in the newborn. Because the risk for neonatal herpes is greater in women with their initial episode during pregnancy, suppression therapy should be started in these women to reduce outbreaks during the third trimester. All women with active lesions at the time of delivery undergo cesarean section. In immunocompromised patients, suppression therapy should be considered. In severe infections of the hospitalized patient, intravenous acyclovir is prescribed.
Fungal (Mycotic) Infections Fungi, tiny members of a subdivision of the plant kingdom that feed on organic matter, are responsible for various common skin infections. In some cases, they affect only the skin and its appendages (ie, hair and nails). In other cases, the internal organs are involved, and this disease may be life-threatening. Superficial infections, however, rarely cause even temporary disability and respond readily to treatment. Secondary infection with bacteria, Candida, or both organisms may occur. The most common fungal skin infection is tinea, which is also called ringworm because of its characteristic appearance of ring or rounded tunnel under the skin. Tinea infections affect the head, body, groin, feet, and nails. Table 56-6 summarizes the tinea infections. To obtain a specimen for diagnosis, the lesion is cleaned, and a scalpel or glass slide is used to remove scales from the margin of the lesion. The scales are dropped onto a slide to which potassium hydroxide has been added. The diagnosis is made by examination
Table 56-6
of the infected scales microscopically for spores and hyphae or by isolating the organism in culture. Under Wood’s light, a specimen of infected hair appears fluorescent; this may be helpful in diagnosing some cases of tinea capitis.
TINEA PEDIS: ATHLETE’S FOOT Tinea pedis (ie, athlete’s foot) is the most common fungal infection. It is especially prevalent in those who use communal showers or swimming pools (Odom et al., 2000).
Clinical Manifestations Tinea pedis may appear as an acute or chronic infection on the soles of the feet or between the toes. The toenail may also be involved. Lymphangitis and cellulitis occur occasionally when bacterial superinfection occurs. Sometimes, a mixed infection involving fungi, bacteria, and yeast occurs.
Medical Management During the acute, vesicular phase, soaks of Burow’s solution or potassium permanganate solutions are used to remove the crusts, scales, and debris and to reduce the inflammation. Topical antifungal agents (eg, miconazole, clotrimazole) are applied to the infected areas. Topical therapy is continued for several weeks because of the high rate of recurrence.
Nursing Management Footwear provides a favorable environment for fungi, and the causative fungus may be in the shoes or socks. Because moisture encourages the growth of fungi, the patient is instructed to keep the feet as dry as possible, including the areas between the toes.
• Tinea (Ringworm) Infections
TYPE AND LOCATION
CLINICAL MANIFESTATIONS
TREATMENT
Tinea capitis (head) Contagious fungal infection of the hair shaft
• Common in children • Oval, scaling, erythematous patches • Small papules or pustules on the scalp • Brittle hair that breaks easily • Begins with red macule, which spreads to a ring of papules or vesicles with central clearing • Lesions found in clusters. • Many spread to the hair, scalp, or nails • Very pruritic • An infected pet may be the source. • Begins with small, red scaling patches, which spread to form circular elevated plaques • Very pruritic • Clusters of pustules may be seen around borders. • Soles of one or both feet have scaling and mild redness with maceration in the toe webs. • More acute infections may have clusters of clear vesicles on dusky base. • Nails thicken, crumble easily, and lack luster • Whole nail may be destroyed.
• Griseofulvin for 6 weeks • Shampoo hair 2 or 3 times with Nizoral or selenium sulfide shampoo.
Tinea corporis (body)
Tinea cruris (groin area; “jock itch”)
Tinea pedis (foot; “athlete’s foot”)
Tinea ungum (toenails; affects about 50% of adults)
• Mild conditions: topical antifungal creams • Severe conditions: griseofulvin or terbinafine
• Mild conditions: topical antifungal creams • Severe conditions: griseofulvin or terbinafine
• Soak feet in vinegar and water solution. • Resistant infections: griseofulvin or terbinafine • Terbinafine (Lamisil) daily for 3 months • Itraconazole (Sporanox) in pulses of 1 week a month for 3 months
Chapter 56 Small pieces of cotton can be placed between the toes at night to absorb moisture. Socks should be made of cotton, and hosiery should have cotton feet, because cotton is an effective absorber of perspiration. For people whose feet perspire excessively, perforated shoes permit better aeration of the feet. Plastic- or rubber-soled footwear should be avoided. Talcum powder or antifungal powder applied twice daily helps to keep the feet dry. Several pairs of shoes should be alternated so that they can dry completely before being worn again.
TINEA CORPORIS: RINGWORM OF THE BODY In tinea corporis (ie, ringworm of the body), the typical ringed lesion appears on the face, neck, trunk, and extremities (Fig. 56-3). Animal (nonhuman) varieties are known to cause an intense inflammatory reaction in humans because they are not adapted to living on human hosts. Humans make contact with animal varieties through contact with pets or objects that have been in contact with an animal.
Medical Management Topical antifungal medication may be applied to small areas. Oral antifungal agents are used only in extensive cases. Side effects of oral antifungal agents include photosensitivity, skin rashes, headache, and nausea. Newer antifungal agents, including itraconazole, fluconazole, and terbinafine, have been more effective with fewer systemic side effects than griseofulvin in patients with chronic fungal (dermatophyte) infections.
Nursing Management The patient is instructed to use a clean towel and washcloth daily. Because fungal infections thrive in heat and moisture, all skin areas and skin folds that retain moisture must be dried thoroughly. Clean cotton clothing should be worn next to the skin.
TINEA CAPITIS: RINGWORM OF THE SCALP Ringworm of the scalp is a contagious fungal infection of the hair shafts and a common cause of hair loss in children. Any child with scaling of the scalp should be considered to have tinea capitis until proven otherwise. Clinical examination reveals one or several round, red scaling patches. Small pustules or papules may
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be seen at the edges of such patches. As the hairs in the affected areas are invaded by the fungi, they become brittle and break off at or near the surface of the scalp, leaving bald patches or the classic sign of black dots, which are the broken ends of hairs. Because most cases of tinea capitis heal without scarring, the hair loss is only temporary.
Medical Management Griseofulvin, an antifungal agent, is prescribed for patients with tinea capitis. Topical agents do not provide an effective cure because the infection occurs within the hair shaft and below the surface of the scalp. However, topical agents can be used to inactivate organisms already on the hair. This minimizes contagion and eliminates the need to clip the hair. Infected hairs break off anyway, and noninfected ones may remain in place. The hair should be shampooed two or three times weekly, and a topical antifungal preparation should be applied to reduce dissemination of the organisms.
Nursing Management Because tinea capitis is contagious, the patient and family should be instructed to set up a hygiene regimen for home use. Each person should have a separate comb and brush and should avoid exchanging hats and other headgear. All infected members of the family must be examined because familial infections are relatively common. Household pets should also be examined.
TINEA CRURIS: RINGWORM OF THE GROIN Tinea cruris (ie, jock itch) is ringworm infection of the groin, which may extend to the inner thighs and buttock area. It occurs most frequently in young joggers, obese people, and those who wear tight underclothing. The incidence of tinea cruris is increased among people with diabetes.
Management Mild infections may be treated with topical medication such as clotrimazole, miconazole, or terbinafine for at least 3 to 4 weeks to ensure eradication of the infection. Oral antifungal agents may be required for more severe infections. Heat, friction, and maceration (from sweating) predispose the patient to the infection. The nurse instructs the patient to avoid excessive heat and humidity as much as possible and to avoid wearing nylon underwear, tight-fitting clothing, and a wet bathing suit. The groin area should be cleaned, dried thoroughly, and dusted with a topical antifungal agent such as tolnaftate (Tinactin) as a preventive measure, because the infection is likely to recur.
TINEA UNGUIUM: ONYCHOMYCOSIS
FIGURE 56-3
Tinea corporis (ringworm) of the face.
Tinea unguium (ie, ringworm of the nails) is a chronic fungal infection of the toenails or, less commonly, the fingernails. It is usually caused by Trichophyton species (T. rubrum, T. mentagrophytes) or Candida albicans. It is usually associated with long-standing fungal infection of the feet. The nails become thickened, friable (ie, easily crumbled), and lusterless. In time, debris accumulates under the free edge of the nail. Ultimately, the nail plate separates. Because of the chronicity of this infection, the entire nail may be destroyed.
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Management
Nursing Management
An oral antifungal agent is prescribed for 6 weeks when the fingernails are involved and 12 weeks when the toenails are involved. Selection of the antifungal agent depends on the causative fungus. Candidal infections are treated with fluconazole (Diflucan) or itraconazole (Sporanox). Griseofulvin is no longer considered effective therapy because of its long treatment course and poor cure rate. Response to oral antifungal agents in treating infections of the toenails is poor at best. Frequently, when the treatment stops, the infection returns.
The nurse informs the patient that head lice may infest anyone and are not a sign of uncleanliness. Because the condition spreads rapidly, treatment must be started immediately. School epidemics may be managed by having all of the students shampoo their hair on the same night. Students should be warned not to share combs, brushes, and hats. Each family member should be inspected for head lice daily for at least 2 weeks. The patient should be instructed that lindane may be toxic to the central nervous system when used improperly.
Parasitic Skin Infestation
PEDICULOSIS CORPORIS AND PUBIS
PEDICULOSIS: LICE INFESTATION
Pediculosis corporis is an infestation of the body by the body louse. This is a disease of unwashed people or those who live in close quarters and do not change their clothing. Pediculosis pubis is extremely common. The infestation is generally localized in the genital region and is transmitted chiefly by sexual contact.
Lice infestation affects people of all ages. Three varieties of lice infest humans: Pediculus humanus capitis (ie, head louse), Pediculus humanus corporis (ie, body louse), and Phthirus pubis (ie, pubic louse or crab louse). Lice are called ectoparasites because they live on the outside of the host’s body. They depend on the host for their nourishment, feeding on human blood approximately five times each day. They inject their digestive juices and excrement into the skin, which causes severe itching.
PEDICULOSIS CAPITIS Pediculosis capitis is an infestation of the scalp by the head louse. The female louse lays her eggs (ie, nits) close to the scalp. The nits become firmly attached to the hair shafts with a tenacious substance. The young lice hatch in about 10 days and reach maturity in 2 weeks.
Clinical Manifestations Head lice are found most commonly along the back of the head and behind the ears. The eggs are visible to the naked eye as silvery, glistening oval bodies that are difficult to remove from the hair. The bite of the insect causes intense itching, and the resultant scratching often leads to secondary bacterial infection, such as impetigo or furunculosis. The infestation is more common in children and people with long hair. Head lice may be transmitted directly by physical contact or indirectly by infested combs, brushes, wigs, hats, and bedding.
Medical Management Treatment involves washing the hair with a shampoo containing lindane (Kwell) or pyrethrin compounds with piperonyl butoxide (RID or R&C Shampoo). The patient is instructed to shampoo the scalp and hair according to the product directions. After the hair is rinsed thoroughly, it is combed with a fine-toothed comb dipped in vinegar to remove any remaining nits or nit shells freed from the hair shafts. They are extremely difficult to remove and may have to be picked off one by one with the fingernails. All articles, clothing, towels, and bedding that may have lice or nits should be washed in hot water—at least 54°C (130°F)— or dry-cleaned to prevent re-infestation. Upholstered furniture, rugs, and floors should be vacuumed frequently. Combs and brushes are also disinfected with the shampoo. All family members and close contacts are treated. Complications such as severe pruritus, pyoderma, and dermatitis are treated with antipruritics, systemic antibiotics, and topical corticosteroids.
Clinical Manifestations Chiefly involved are those areas of the skin that come in closest contact with the underclothing (ie, neck, trunk, and thighs). The body louse lives primarily in the seams of underwear and clothing, to which it clings as it pierces the skin with its proboscis. Its bites cause characteristic minute hemorrhagic points. Widespread excoriation may appear as a result of intense itching and scratching, especially on the trunk and neck. Among the secondary lesions produced are parallel linear scratches and a slight degree of eczema. In long-standing cases, the skin may become thick, dry, and scaly, with dark pigmented areas. Itching is the most common symptom of pediculosis pubis, particularly at night. Reddish brown dust (ie, excretions of the insects) may be found in the patient’s underclothing. The pubic area should be examined with a magnifying glass for lice crawling down a hair shaft or nits cemented to the hair or at the junction with the skin. Infestation by pubic lice may coexist with sexually transmitted diseases such as gonorrhea, herpes, or syphilis. There may also be infestation of the hairs of the chest, armpit, beard, and eyelashes. Gray-blue macules may sometimes be seen on the trunk, thighs, and axillae as a result of either the reaction of the insects’ saliva with bilirubin (converting it to biliverdin) or an excretion produced by the salivary glands of the louse.
Medical Management The patient is instructed to bathe with soap and water, after which lindane (Kwell) or 5% permethrin (Elimite) is applied to affected areas of the skin and to hairy areas, according to the product directions. An alternative topical therapy is an over-thecounter strength of permethrin (1% Nix). If the eyelashes are involved, petrolatum may be thickly applied twice daily for 8 days, followed by mechanical removal of any remaining nits. Complications, such as severe pruritus, pyoderma, and dermatitis, are treated with antipruritics, systemic antibiotics, and topical corticosteroids. Body lice can transmit epidemic rickettsial disease to humans such as epidemic typhus, relapsing fever, and trench fever. The causative organism may be in the gastrointestinal tract of the insect and may be excreted on the skin surface of the infested person.
Chapter 56 Nursing Management All family members and sexual contacts must be treated and educated in personal hygiene and methods to prevent or control infestation. The patient and partner must also be scheduled for a diagnostic workup for coexisting sexually transmitted disease. All clothing and bedding should be machine washed in hot water or dry-cleaned.
SCABIES Scabies is an infestation of the skin by the itch mite Sarcoptes scabiei. The disease may be found in people living in substandard hygienic conditions, but it is also common in very clean individuals and among the sexually active, although infestations do not depend on sexual activity. The mites frequently involve the fingers, and hand contact may produce infection. In children, overnight stays with friends or the exchange of clothes may be a source of infection. Health care personnel who have prolonged hands-on physical contact with an infected patient may likewise become infected. The adult female burrows into the superficial layer of the skin and remains there for the rest of her life. With her jaws and the sharp edges of the joints of her forelegs, the mite extends the burrow, laying two or three eggs daily for up to 2 months. She then dies. The larvae hatch from the eggs in 3 to 4 days and progress through larval and nymphal states to form adult mites in about 10 days.
Clinical Manifestations It takes approximately 4 weeks from the time of contact for the patient’s symptoms to appear. The patient complains of severe itching caused by a delayed type of immunologic reaction to the mite or its fecal pellets. During examination, the patient is asked where the itch is most severe. A magnifying glass and a penlight are held at an oblique angle to the skin while a search is made for the small, raised burrows. The burrows may be multiple, straight or wavy, brown or black, threadlike lesions, most commonly observed between the fingers and on the wrists. Other sites are the extensor surfaces of the elbows, the knees, the edges of the feet, the points of the elbows, around the nipples, in the axillary folds, under pendulous breasts, and in or near the groin or gluteal fold, penis, or scrotum. Red, pruritic eruptions usually appear between adjacent skin areas. The burrow, however, is not always visible. Any patient with a rash may have scabies. One classic sign of scabies is the increased itching that occurs at night, perhaps because the increased warmth of the skin has a stimulating effect on the parasite. Hypersensitivity to the organism and its products of excretion also may contribute to the itching. If the infection has spread, other members of the family and close friends also complain of itching about a month later. Secondary lesions are quite common and include vesicles, papules, excoriations, and crusts. Bacterial superinfection may result from constant excoriation of the burrows and papules.
Assessment and Diagnostic Findings The diagnosis is confirmed by recovering S. scabiei or the mites’ byproducts from the skin. A sample of superficial epidermis is scraped off the top of the burrows or papules with a small scalpel blade. The scrapings are placed on a microscope slide and examined through a low-powered microscope to demonstrate the mite
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at any stage (eg, egg, egg casing, larva, nymph, adult) and fecal pellets. Gerontologic Considerations Elderly patients living in long-term care facilities are more susceptible to outbreaks of scabies because of close living quarters, poor hygiene due to limited physical ability, and the potential for incidental spread of the organisms by nursing staff. Although the older patient itches severely, the vivid inflammatory reaction seen in younger people seldom occurs. Scabies may not be recognized in the elderly person; the itching may erroneously be attributed to the dry skin of old age or to anxiety. Health care personnel in extended-care facilities should wear gloves when providing hands-on care for a patient suspected of having scabies until the diagnosis is confirmed and treatment accomplished. It is advisable to treat all residents, staff, and families of patients at the same time to prevent reinfection. Because geriatric patients may be more sensitive to side effects of the scabicides, they should be closely observed for reactions.
Medical Management The patient is instructed to take a warm, soapy bath or shower to remove the scaling debris from the crusts and then to dry thoroughly and allow the skin to cool. A prescription scabicide, such as lindane (Kwell), crotamiton (Eurax), or 5% permethrin (Elimite), is applied thinly to the entire skin from the neck down, sparing only the face and scalp (which are not affected in scabies). The medication is left on for 12 to 24 hours, after which the patient is instructed to wash thoroughly. One application may be curative, but it is advisable to repeat the treatment in 1 week.
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NURSING ALERT The patient must understand medication instructions, because application of a scabicide immediately after bathing and before the skin dries and cools increases percutaneous absorption of the scabicide and the potential for central nervous system abnormalities such as seizures.
Nursing Management The patient should wear clean clothing and sleep between freshly laundered bed linens. All bedding and clothing should be washed in hot water and dried on the hot dryer cycle, because the mites can survive up to 36 hours in linens. If bed linens or clothing cannot be washed in hot water, dry-cleaning is advised. After treatment is completed, the patient should apply an ointment, such as a topical corticosteroid, to skin lesions because the scabicide may irritate the skin. The patient’s hypersensitivity does not cease on destruction of the mites. Itching may continue for several weeks as a manifestation of hypersensitivity, particularly in atopic (allergic) people. This is not a sign that the treatment has failed. The patient is instructed not to apply more scabicide because it will cause more irritation and increased itching and advised not to take frequent hot showers because they can dry the skin and produce itching. Oral antihistamines such as diphenhydramine (Benadryl) or hydroxyzine (Atarax) can help control the itching. All family members and close contacts should be treated simultaneously to eliminate the mites. Some scabicides are approved for use in infants and pregnant women. If scabies is sexually
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transmitted, the patient may require treatment for coexisting sexually transmitted disease. Scabies may also coexist with pediculosis.
Contact Dermatitis Contact dermatitis is an inflammatory reaction of the skin to physical, chemical, or biologic agents. The epidermis is damaged by repeated physical and chemical irritations. Contact dermatitis may be of the primary irritant type, in which a nonallergic reaction results from exposure to an irritating substance, or it may be allergic (ie, allergic contact dermatitis), resulting from exposure of sensitized people to contact allergens. Allergic dermatoses are discussed in Chapter 53. Common causes of irritant dermatitis are soaps, detergents, scouring compounds, and industrial chemicals. Predisposing factors include extremes of heat and cold, frequent contact with soap and water, and a preexisting skin disease (Chart 56-3).
Clinical Manifestations The eruptions begin when the causative agent contacts the skin. The first reactions include itching, burning, and erythema, followed closely by edema, papules, vesicles, and oozing or weeping. In the subacute phase, these vesicular changes are less marked, and they alternate with crusting, drying, fissuring, and peeling. If repeated reactions occur or if the patient continually scratches the skin, lichenification and pigmentation occur. Secondary bacterial invasion may follow.
Medical Management The objectives of management are to rest the involved skin and protect it from further damage. The distribution pattern of the reaction is determined to differentiate between allergic and irritant contact dermatitis. A detailed history is obtained. If indicated, the offending irritant is removed. Local irritation should be avoided, and soap is not generally used until healing occurs.
Chart 56-3 • PATIENT EDUCATION Strategies for Avoiding Contact Dermatitis The following precautions may help prevent repeated cases of contact dermatitis. Follow these instructions for at least 4 months after your skin appears to be completely healed. • Study the pattern and location of your dermatitis and think about which things have touched your skin and which things may have caused the problem. • Try to avoid contact with these materials. • Avoid heat, soap, and rubbing, all of which are external irritants. • Choose bath soaps, laundry detergents, and cosmetics that do not contain fragrance. • Avoid using a fabric softener dryer sheet (Bounce, Cling). Fabric softeners that are added to the washer may be used. • Avoid topical medications, lotions, or ointments, except those specifically prescribed for your condition. • Wash your skin thoroughly immediately after exposure to possible irritants. • When wearing gloves (for example, for washing dishes or general cleaning), be sure they are cotton-lined. Do not wear them more than 15 or 20 minutes at a time.
Many preparations are advocated for relieving dermatitis. In general, a bland, unmedicated lotion is used for small patches of erythema (ie, red, inflamed skin). Cool, wet dressings also are applied over small areas of vesicular dermatitis. Finely cracked ice added to the water often enhances its antipruritic effect. Wet dressings usually help clear the oozing eczematous lesions. A thin layer of cream or ointment containing a corticosteroid then may be used. Medicated baths at room temperature are prescribed for larger areas of dermatitis. For severe, widespread conditions, a short course of systemic corticosteroids may be prescribed.
Noninfectious Inflammatory Dermatoses PSORIASIS Psoriasis is a chronic noninfectious inflammatory disease of the skin in which epidermal cells are produced at a rate that is about six to nine times faster than normal. The cells in the basal layer of the skin divide too quickly, and the newly formed cells move so rapidly to the skin surface that they become evident as profuse scales or plaques of epidermal tissue. The psoriatic epidermal cell may travel from the basal cell layer of the epidermis to the stratum corneum (ie, skin surface) and be cast off in 3 to 4 days, which is in sharp contrast to the normal 26 to 28 days. As a result of the increased number of basal cells and rapid cell passage, the normal events of cell maturation and growth cannot take place. This abnormal process does not allow the normal protective layers of the skin to form. One of the most common skin diseases, psoriasis affects approximately 2% of the population, appearing more often in people who have a European ancestry. It is thought that the condition stems from a hereditary defect that causes overproduction of keratin. Although the primary cause is unknown, a combination of specific genetic makeup and environmental stimuli may trigger the onset of disease. There is some evidence that the cell proliferation is mediated by the immune system. Periods of emotional stress and anxiety aggravate the condition. Trauma, infections, and seasonal and hormonal changes also are trigger factors. The onset may occur at any age but is most common between the ages of 15 and 50 years. Psoriasis has a tendency to improve and then recur periodically throughout life (Champion et al., 1998).
Clinical Manifestations Lesions appear as red, raised patches of skin covered with silvery scales. The scaly patches are formed by the buildup of living and dead skin resulting from the vast increase in the rate of skin-cell growth and turnover (Fig. 56-4). If the scales are scraped away, the dark red base of the lesion is exposed, producing multiple bleeding points. These patches are not moist and may be pruritic. One variation of this condition is called guttate psoriasis because the lesions remain about 1 cm wide and are scattered like raindrops over the body. This variation is believed to be associated with a recent streptococcal throat infection. Psoriasis may range in severity from a cosmetic source of annoyance to a physically disabling and disfiguring disorder. Particular sites of the body tend to be affected most by this condition; they include the scalp, the extensor surface of the elbows and knees, the lower part of the back, and the genitalia. Bilateral symmetry is a feature of psoriasis. In approximately one fourth to one half of patients, the nails are involved, with pitting, discoloration, crumbling beneath the free edges, and separation of the nail plate. When psoriasis occurs on the palms and soles, it can cause pustular lesions called palmar pustular psoriasis.
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of the skin is of little diagnostic value. There are no specific blood tests helpful in diagnosing the condition. When in doubt, the health professional should assess for signs of nail and scalp involvement and for a positive family history.
Medical Management
FIGURE 56-4
Psoriasis. Courtesy of Roche Laboratories.
Complications The disease may be associated with asymmetric rheumatoid factor– negative arthritis of multiple joints. The arthritic development can occur before or after the skin lesions appear. The relation between arthritis and psoriasis is not understood. Another complication is an exfoliative psoriatic state in which the disease progresses to involve the total body surface, called erythrodermic psoriasis. In this case, the patient is more acutely ill, with fever, chills, and an electrolyte imbalance. Erythrodermic psoriasis often appears in people with chronic psoriasis after infections or after exposure to certain medications, including withdrawal of systemic corticosteroids (Champion et al., 1998).
Assessment and Diagnostic Findings The presence of the classic plaque-type lesions generally confirms the diagnosis of psoriasis. Because the lesions tend to change histologically as they progress from early to chronic plaques, biopsy
Table 56-7
The goals of management are to slow the rapid turnover of epidermis, to promote resolution of the psoriatic lesions, and to control the natural cycles of the disease. There is no known cure. The therapeutic approach should be one that the patient understands; it should be cosmetically acceptable and not too disruptive of lifestyle. Treatment involves the commitment of time and effort by the patient and possibly the family. First, any precipitating or aggravating factors are addressed. An assessment is made of lifestyle, because psoriasis is significantly affected by stress. The patient is informed that treatment of severe psoriasis can be time consuming, expensive, and aesthetically unappealing at times. The most important principle of psoriasis treatment is gentle removal of scales. This can be accomplished with baths. Oils (eg, olive oil, mineral oil, Aveeno Oilated Oatmeal Bath) or coal tar preparations (eg, Balnetar) can be added to the bath water and a soft brush used to scrub the psoriatic plaques gently. After bathing, the application of emollient creams containing alphahydroxy acids (eg, Lac-Hydrin, Penederm) or salicylic acid will continue to soften thick scales. The patient and family should be encouraged to establish a regular skin care routine that can be maintained even when the psoriasis is not in an acute stage. PHARMACOLOGIC THERAPY Three types of therapy are standard: topical, intralesional, and systemic (Table 56-7). Topical Agents. Topically applied agents are used to slow the overactive epidermis without affecting other tissues. Medications include tar preparations, anthralin, salicylic acid, and corticosteroids. Two topical treatments introduced within the last few years are a vitamin D preparation, calcipotriene (Dovonex), and
• Current Treatments for Psoriasis
TOPICAL AGENTS
USE
SELECTED AGENTS
Topical corticosteroids
Topical nonsteroidals
Mild to moderate lesions Moderate to severe lesions Severe lesions Lesions on face and groin Mild to severe
Coal tar products
Mild to moderate lesions
Medicated shampoos
Scalp lesions
Intralesional therapy Systemic therapy
Thick plaques and nails Extensive lesions and nails
Photochemotherapy
Psoriatic arthritis Moderate to severe lesions
Aristocort, Kenalog, Valisone Lidex, Psorcon, Cutivate Temovate, Diprolene, Ultravate Aclovate, DesOwen, Hytone 2.5% Retinoids such as tazarotene (Tazorac) Vitamin D3 derivative calcipotriene (Dovonex) Coal tar and salicylic acid ointment (Aquatar, Estar gel, Fototar, Zetar); anthralin (AnthraDerm, Dritho-Cream); Neutrogena T-Derm, Psori Gel Neutrogena T-Gel, T-Sal, Zetar, Head & Shoulders, Desenex, Selsun Blue, Bakers P&S (emulsifying agent with phenol, saline solution, and mineral oil) Kenalog, Cordran-impregnated tape, Fluoroplex Methotrexate (Folex, Mexate); hydrourea (Hydrea); retinoic acid (Tegison) (not to be used in women of childbearing age) Oral gold (auranofin), etrentinate, methotrexate UVA or UVB light with or without topical medications PUVA (combines UVA light with oral psoralens, or topical tripsoralen)
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a retinoid compound, tazarotene (Tazorac). Treatment with these agents tends to suppress epidermopoiesis (ie, development of epidermal cells) and cause sloughing of the rapidly growing epidermal cells. Topical formulations include lotions, ointments, pastes, creams, and shampoos. Older treatments, including tar baths and application of tar preparations on involved skin, are rarely used. Tar and anthralin cause irritation of the skin at the sites of application, are malodorous and difficult to apply, and do not give reliable results. Newer preparations that cause less irritation and have more consistent results are becoming more widely used. Topical corticosteroids may be applied for their antiinflammatory effect. Choosing the correct strength of corticosteroid for the involved site and choosing the most effective vehicle base are important aspects of topical treatment. In general, highpotency topical corticosteroids should not be used on the face and intertriginous areas, and their use on other areas should be limited to a 4-week course of twice-daily applications. A 2-week break should be taken before repeating treatment with the high-potency corticosteroids. For long-term therapy, moderate-potency corticosteroids are used. On the face and intertriginous areas, only low-potency corticosteroids are appropriate for long-term use (see Table 56-4). Occlusive dressings may be applied to increase the effectiveness of the corticosteroid. For the hospitalized patient, large plastic bags may be used—one for the upper body with openings cut for the head and arms and one for the lower body with openings for the legs. This leaves only the extremities to wrap. In some dermatologic units, large rolls of tubular plastic are used, such as those used by dry-cleaners. For patients being treated at home, a vinyl jogging suit may be used. The medication is applied, and the suit is put on over it. The hands can be wrapped in gloves, the feet in plastic bags, and the head in a shower cap. Occlusive dressings should not remain in place longer than 8 hours. The nurse should very carefully inspect the skin for the appearance of atrophy and telangiectasias which are side effects of corticosteroids.
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NURSING ALERT When plastic substances are used, the nurse needs to check for flammability. Some thin plastic films burn slowly (if touched by a lighted cigarette), whereas others burst rapidly into flame. The patient should be cautioned not to smoke while wrapped in plastic dressing.
When psoriasis involves large areas of the body, topical corticosteroid treatment can become expensive and involve some systemic risk. Some potent corticosteroids, when applied to large areas of the body, have the potential to cause adrenal suppression through percutaneous absorption of the medication. In this event, other treatment modalities (eg, nonsteroidal topical medications, ultraviolet light) may be used instead or in combination to decrease the need for corticosteroids. Newer nonsteroidal topical preparations are available and effective for many patients. Calcipotriene 0.05% (Dovonex) is a derivative of vitamin D2. It works to decrease the mitotic turnover of the psoriatic plaques. Its most common side effect is local irritation, and the intertriginous areas and face should be avoided when using this medication. Patients should be monitored for symptoms of hypercalcemia. It is available as a cream for use on the body and a solution for the scalp. Calcipotriene is not recommended for use by elderly patients because of their more fragile skin or for pregnant or lactating women. The second advance in topical treatment of psoriasis is tazarotene (Tazorac). Tazarotene, a retinoid, causes sloughing of the scales
covering psoriatic plaques. As with other retinoids, it causes increased sensitivity to sunlight, so patients should be cautioned to use an effective sunscreen and avoid other photosensitizers (eg, tetracycline, antihistamines). Tazarotene is listed as a Category X drug in pregnancy; reports indicate evidence of fetal risk, and the risk of use in pregnant women clearly outweighs any possible benefits. A negative result on a pregnancy test should be obtained before initiating this medication, and an effective contraceptive should be continued during treatment. Side effects of tazarotene include burning, erythema, or irritation at the site of application and worsening of psoriasis. Intralesional Agents. Intralesional injections of triamcinolone acetonide (Aristocort, Kenalog-10, Trymex) can be administered directly into highly visible or isolated patches of psoriasis that are resistant to other forms of therapy. Care must be taken to ensure that normal skin is not injected with the medication. Systemic Agents. Although systemic corticosteroids may cause rapid improvement of psoriasis, their usual risks and the possibility of triggering a severe flare-up on withdrawal limit their use. Systemic cytotoxic preparations, such as methotrexate, have been used in treating extensive psoriasis that fails to respond to other forms of therapy. Other systemic medications in current use include hydroxyurea (Hydrea) and cyclosporine A (CyA). Methotrexate appears to inhibit DNA synthesis in epidermal cells, thereby reducing the turnover time of the psoriatic epidermis. However, the medication can be toxic, especially to the liver, which can suffer irreversible damage. Laboratory studies must be monitored to ensure that the hepatic, hematopoietic, and renal systems are functioning adequately. Bone marrow suppression is another potential side effect. The patient should avoid drinking alcohol while taking methotrexate, because alcohol ingestion increases the possibility of liver damage. The medication is teratogenic (ie, producing physical defects in the fetus) and should not be administered to pregnant women. Hydroxyurea also inhibits cell replication by affecting DNA synthesis. The patient is monitored for signs and symptoms of bone marrow depression. Cyclosporine A, a cyclic peptide used to prevent rejection of transplanted organs, has shown some success in treating severe, therapy-resistant cases of psoriasis. Its use, however, is limited by side effects such as hypertension and nephrotoxicity. Oral retinoids (ie, synthetic derivatives of vitamin A and its metabolite, vitamin A acid) modulate the growth and differentiation of epithelial tissue. Etretinate is especially useful for severe pustular or erythrodermic psoriasis. Etretinate is a teratogen with a very long half-life; it cannot be used in women with childbearing potential. PHOTOCHEMOTHERAPY One treatment for severely debilitating psoriasis is a psoralen medication combined with ultraviolet-A (PUVA) light therapy. Ultraviolet light is the portion of the electromagnetic spectrum containing wavelengths ranging from 180 to 400 nm. In this treatment, the patient takes a photosensitizing medication (usually 8-methoxypsoralen) in a standard dose and is subsequently exposed to long-wave ultraviolet light as the medication plasma levels peak. Although the mechanism of action is not completely understood, it is thought that when psoralen-treated skin is exposed to ultraviolet-A light, the psoralen binds with DNA and decreases cellular proliferation. PUVA is not without its hazards;
Chapter 56 it has been associated with long-term risks of skin cancer, cataracts, and premature aging of the skin. The PUVA unit consists of a chamber that contains highoutput black-light lamps and an external reflectance system. The exposure time is calibrated according to the specific unit in use and the anticipated tolerance of the patient’s skin. The patient is usually treated two or three times each week until the psoriasis clears. An interim period of 48 hours between treatments is necessary because it takes this long for any burns resulting from PUVA therapy to become evident. After the psoriasis clears, the patient begins a maintenance program. Once little or no disease is active, less potent therapies are used to keep minor flare-ups under control. Ultraviolet-B (UVB) light therapy is also used to treat generalized plaques. UVB light ranges from 270 to 350 nm, although research has shown that a narrow range, 310 to 312 nm, is the action spectrum. It is used alone or combined with topical coal tar. Side effects are similar to those of PUVA therapy. A new development in light therapy is the narrow-band UVB, which ranges from 311 to 312 nm, decreasing exposure to harmful ultraviolet energy while providing more intense, specific therapy (Shelk & Morgan, 2000). If access to a light treatment unit is not feasible, the patient can expose himself or herself to sunlight. The risks of all light treatments are similar and include acute sunburn reaction; exacerbation of photosensitive disorders such as lupus, rosacea, and polymorphic light eruption; and other skin changes such as increased wrinkles, thickening, and an increased risk for skin cancer. Excimer lasers have come into use in treating psoriasis. These lasers function at 308 nm. Studies show that medium-sized psoriatic plaques clear in four to six treatments and remain clear for up to 9 months. A laser can be more effective on the scalp or on other hard-to-treat areas, because the laser can be aimed very specifically on the plaque (Lebwohl, 2000). Table 56-7 summarizes the treatment plans.
NURSING PROCESS: CARE OF THE PATIENT WITH PSORIASIS Assessment The nursing assessment focuses on how the patient is coping with the psoriatic skin condition, appearance of the normal skin, and appearance of the skin lesions, as described previously. The notable manifestations are red, scaling papules that coalesce to form oval, well-defined plaques. Silver-white scales may also be present. Adjacent skin areas show red, smooth plaques with a macerated surface. It is important to examine the areas especially prone to psoriasis: elbows, knees, scalp, gluteal cleft, fingers, and toenails (for small pits). Psoriasis may cause despair and frustration for the patient; observers may stare, comment, ask embarrassing questions, or even avoid the person. The disease can eventually exhaust the patient’s resources, interfere with his or her job, and make life miserable in general. Teenagers are especially vulnerable to the psychological effects of this disorder. The family, too, is affected, because timeconsuming treatments, messy salves, and constant shedding of scales may disrupt home life and cause resentment. The patient’s frustrations may be expressed through hostility directed at health care personnel and others. The nurse assesses the impact of the disease on the patient and the coping strategies used for conducting normal activities and interactions with family and friends. Many patients need reassurance that the condition is not infectious, not a reflection of poor personal hygiene, and not skin cancer.
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Diagnosis NURSING DIAGNOSES Based on the nursing assessment data, the patient’s major nursing diagnoses may include the following:
• Deficient knowledge about the disease process and treatment
• Impaired skin integrity related to lesions and inflammatory response
• Disturbed body image related to embarrassment over appearance and self-perception of uncleanliness
COLLABORATIVE PROBLEMS/ POTENTIAL COMPLICATIONS Based on the assessment data, potential complications include the following:
• Infection • Psoriatic arthritis Planning and Goals Major goals for the patient may include increased understanding of psoriasis and the treatment regimen, achievement of smoother skin with control of lesions, development of self-acceptance, and absence of complications.
Nursing Interventions PROMOTING UNDERSTANDING The nurse explains with sensitivity that, although there is no cure for psoriasis and lifetime management is necessary, the condition can usually be controlled. The pathophysiology of psoriasis is reviewed, as are the factors that provoke it—irritation or injury to the skin (eg, cut, abrasion, sunburn), current illness (eg, pharyngeal streptococcal infection), and emotional stress. It is emphasized that repeated trauma to the skin and an unfavorable environment (eg, cold) or a specific medication (eg, lithium, betablockers, indomethacin) may exacerbate psoriasis. The patient is cautioned about taking any nonprescription medications because some may aggravate mild psoriasis. Reviewing and explaining the treatment regimen are essential to ensure compliance. For example, if the patient has a mild condition confined to localized areas, such as the elbows or knees, application of an emollient to maintain softness and minimize scaling may be all that is required. However, if the patient uses anthralin, the dosage schedule, possible side effects, and problems to report to the nurse or physician should be explained. Most patients need a comprehensive plan of care that ranges from using topical medications and shampoos to more complex and lengthy treatment with systemic medications and photochemotherapy, such as PUVA therapy. Patient education materials that include a description of the therapy and specific guidelines are helpful but cannot replace face-to-face discussions of the treatment plan. INCREASING SKIN INTEGRITY To avoid injuring the skin, the patient is advised not to pick at or scratch the affected areas. Measures to prevent dry skin are encouraged because dry skin worsens psoriasis. Too-frequent washing produces more soreness and scaling. Water should be warm, not hot, and the skin should be dried by patting with a towel rather than by rubbing. Emollients have a moisturizing effect,
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providing an occlusive film on the skin surface so that normal water loss through the skin is halted and allowing the trapped water to hydrate the stratum corneum. A bath oil or emollient cleansing agent can comfort sore and scaling skin. Softening the skin can prevent fissures (see Plan of Nursing Care 56-1). IMPROVING SELF-CONCEPT AND BODY IMAGE A therapeutic relationship between health care professionals and the patient with psoriasis is one that includes education and support. After the treatment regimen is established, the patient should begin to feel more confident and empowered in carrying it out and in using coping strategies that help deal with the altered selfconcept and body image brought about by the disease. Introducing the patient to successful coping strategies used by others with psoriasis and making suggestions for reducing or coping with stressful situations at home, school, and work can facilitate a more positive outlook and acceptance of the chronicity of the disease. MONITORING AND MANAGING POTENTIAL COMPLICATIONS Psoriatic Arthritis The diagnosis of psoriasis, especially when it is accompanied by the complication of arthritis, is usually difficult to make. Psoriatic arthritis involving the sacroiliac and distal joints of the fingers may be overlooked, especially if the patient has the typical psoriatic lesions. However, patients who complain of mild joint discomfort and some pitting of the fingernails may not be diagnosed with psoriasis until the more obvious cutaneous lesions appear. The complaint of joint discomfort in the patient with psoriasis should be noted and evaluated. The symptoms of psoriatic arthritis can mimic the symptoms of Reiter’s disease and ankylosing spondylitis, and a definitive diagnosis must be made. Treatment of the condition usually involves joint rest, application of heat, and salicylates. The patient requires education about the care and treatment of the involved joints and the need for compliance with therapy. The incidence of psoriatic arthropathy is unknown because the symptoms are so variable. It is believed, however, that when the psoriasis is extensive and a family history of inflammatory arthritis is elicited, the chance that the patient will develop psoriatic arthritis increases substantially. It is recommended that a rheumatologist be consulted to assist in the diagnosis and treatment of the arthropathy. PROMOTING HOME AND COMMUNITY-BASED CARE Teaching Patients Self-Care Printed patient education materials may be provided to reinforce face-to-face discussions about treatment guidelines and other con-
siderations. For example, the patient and the family caregiver may need to know that the topical agent anthralin leaves a brownish purple stain on the skin but that the discoloration subsides after anthralin treatment stops. The patient should also be instructed to cover lesions treated with anthralin with gauze, stockinette, or other soft coverings to avoid staining clothing, furniture, and bed linens. Patients using topical corticosteroid preparations repeatedly on the face and around the eyes should be aware that cataract development is possible. Strict guidelines for applying these medications should be emphasized because overuse can result in skin atrophy, striae, and medication resistance. Photochemotherapy (PUVA), which is reserved for moderate to severe psoriasis, produces photosensitization, which means that the skin is sensitive to the sun until methoxsalen has been excreted from the body in about 6 to 8 hours. Patients undergoing PUVA treatments should avoid exposure to the sun. If exposure is unavoidable, the skin must be protected with sunscreen and clothing. Gray- or green-tinted, wraparound sunglasses should be worn to protect the eyes during and after treatment, and ophthalmologic examinations should be performed on a regular basis. Nausea, which may be a problem in some patients, is lessened when methoxsalen is taken with food. Lubricants and bath oils may be used to help remove scales and prevent excessive dryness. No other creams or oils are to be used except on areas that have been shielded from ultraviolet light. Contraceptives should be used by sexually active women of reproductive age, because the teratogenic effect of PUVA has not been determined. The patient is kept under constant and careful supervision and is encouraged to recognize unusual changes in the skin. If indicated, referral may be made to a mental health professional who can help to ease emotional strain and give support. Belonging to a support group may also help patients acknowledge that they are not alone in experiencing life adjustments in response to a visible, chronic disease. The National Psoriasis Foundation publishes periodic bulletins and reports about new and relevant developments in this condition. Chart 56-4 is a Home Care Checklist for the patient with psoriasis.
Evaluation EXPECTED PATIENT OUTCOMES Expected patient outcomes may include the following: 1. Demonstrates knowledge and understanding of disease process and its treatment a. Describes psoriasis and the prescribed therapy b. Verbalizes that trauma, infection, and emotional stress may be trigger factors
Chart 56-4 Home Care Checklist • The Patient With Psoriasis At the completion of the home care instruction, the patient or caregiver will be able to: • Describe the etiology of psoriasis. • Describe optimal skin maintenance practices to maintain moisture of skin and prevent infection. • Demonstrate proper application of prescribed topical medications. • Describe common side effects of oral medication, if prescribed. • Demonstrate appropriate therapeutic bath technique, if prescribed. • Verbalize optimism about condition. • Identify a support person with whom to discuss feelings and concerns.
Patient
Caregiver
✓ ✓ ✓ ✓ ✓ ✓ ✓
✓ ✓ ✓ ✓ ✓
Chapter 56 c. Maintains control with appropriate therapy d. Demonstrates proper application of topical therapy 2. Achieves smoother skin and control of lesions a. Exhibits no new lesions b. Keeps skin lubricated and soft 3. Develops self-acceptance a. Identifies someone with whom to discuss feelings and concerns b. Expresses optimism about outcomes of treatment 4. Absense of complications a. Has no joint discomfort b. Reports control of cutaneous lesions with no extension of disease
EXFOLIATIVE DERMATITIS Exfoliative dermatitis is a serious condition characterized by progressive inflammation in which erythema and scaling occur in a more or less generalized distribution. It may be associated with chills, fever, prostration, severe toxicity, and an itchy scaling of the skin. There is a profound loss of stratum corneum (ie, outermost layer of the skin), which causes capillary leakage, hypoproteinemia, and negative nitrogen balance. Because of widespread dilation of cutaneous vessels, large amounts of body heat are lost, and exfoliative dermatitis has a marked effect on the entire body. Exfoliative dermatitis has a variety of causes. It is considered to be a secondary or reactive process to an underlying skin or systemic disease. It may appear as a part of the lymphoma group of diseases and may precede the appearance of lymphoma. Preexisting skin disorders that have been implicated as a cause include psoriasis, atopic dermatitis, and contact dermatitis. It also appears as a severe reaction to many medications, including penicillin and phenylbutazone. The cause is unknown in approximately 25% of cases (Odom et al., 2000).
Clinical Manifestations This condition starts acutely as a patchy or a generalized erythematous eruption accompanied by fever, malaise, and occasionally gastrointestinal symptoms. The skin color changes from pink to dark red. After a week, the characteristic exfoliation (ie, scaling) begins, usually in the form of thin flakes that leave the underlying skin smooth and red, with new scales forming as the older ones come off. Hair loss may accompany this disorder. Relapses are common. The systemic effects include high-output heart failure, intestinal disturbances, breast enlargement, elevated levels of uric acid in the blood (ie, hyperuricemia), and temperature disturbances.
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Nursing Management Continual nursing assessment is carried out to detect infection. The disrupted, erythematous, moist skin is susceptible to infection and becomes colonized with pathogenic organisms, which produce more inflammation. Antibiotics, prescribed if infection is present, are selected on the basis of culture and sensitivity.
!
NURSING ALERT The nurse observes the patient for signs and symptoms of heart failure because hyperemia and increased cutaneous blood flow can produce high-output cardiac failure.
Hypothermia may occur because increased blood flow in the skin, coupled with increased water loss through the skin, leads to heat loss by radiation, conduction, and evaporation. Changes in vital signs are closely monitored and reported. As in any acute dermatitis, topical therapy is used to provide symptomatic relief. Soothing baths, compresses, and lubrication with emollients are used to treat the extensive dermatitis. The patient is likely to be extremely irritable because of the severe itching. Oral or parenteral corticosteroids may be prescribed when the disease is not controlled by more conservative therapy. When a specific cause is known, more specific therapy may be used. The patient is advised to avoid all irritants in the future, particularly medications.
Blistering Diseases Blisters of the skin have many origins, including bacterial, fungal, or viral infections; allergic contact reactions; burns; metabolic disorders; and immunologically mediated reactions. Some of these have been discussed previously (eg, herpes simplex and zoster infections, contact dermatitis). Immunologically mediated diseases are autoimmune reactions and represent a defect of IgM, IgE, IgG, and C3. Some of these conditions are life-threatening; others become chronic problems. The diagnosis is always made by histologic examination of a biopsy specimen by a dermatopathologist. A specimen from the blister and surrounding skin demonstrates acantholysis (ie, separation of epidermal cells from each other because of damage to or an abnormality of the intracellular substance). Circulating antibodies may be detected by immunofluorescent studies of the patient’s serum.
PEMPHIGUS Medical Management The objectives of management are to maintain fluid and electrolyte balance and to prevent infection. The treatment is individualized and supportive and should be initiated as soon as the condition is diagnosed. The patient may be hospitalized and placed on bed rest. All medications that may be implicated are discontinued. A comfortable room temperature should be maintained because the patient does not have normal thermoregulatory control as a result of temperature fluctuations caused by vasodilation and evaporative water loss. Fluid and electrolyte balance must be maintained because there is considerable water and protein loss from the skin surface. Plasma volume expanders may be indicated.
Pemphigus is a group of serious diseases of the skin characterized by the appearance of bullae (ie, blisters) of various sizes on apparently normal skin (Fig. 56-5) and mucous membranes. Available evidence indicates that pemphigus is an autoimmune disease involving immunoglobulin G. It is thought that the pemphigus antibody is directed against a specific cell-surface antigen in epidermal cells. A blister forms from the antigen–antibody reaction. The level of serum antibody is predictive of disease severity. Genetic factors may also play a role in its development, with the highest incidence among those of Jewish or Mediterranean descent. This disorder usually occurs in men and women in middle and late adulthood. The condition may be associated with penicillins and captopril and with myasthenia gravis.
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BULLOUS PEMPHIGOID Bullous pemphigoid is an acquired disease of flaccid blisters appearing on normal or erythematous skin. It appears more often on the flexor surfaces of the arms, legs, axilla, and groin. Oral lesions, if present, are usually transient and minimal. When the blisters break, the skin has shallow erosions that heal fairly quickly. Pruritus can be intense, even before the appearance of the blisters. Bullous pemphigoid is common in the elderly, with a peak incidence at about 60 years of age. There is no gender or racial predilection, and the disease can be found throughout the world.
Management FIGURE 56-5
Vesicles on the chin (in pemphigus). Sauer, G. C. (1985). Manual of Skin Diseases. Philadelphia: J. B. Lippincott.
Clinical Manifestations Most patients present with oral lesions appearing as irregularly shaped erosions that are painful, bleed easily, and heal slowly. The skin bullae enlarge, rupture, and leave large, painful eroded areas that are accompanied by crusting and oozing. A characteristic offensive odor emanates from the bullae and the exuding serum. There is blistering or sloughing of uninvolved skin when minimal pressure is applied (ie, Nikolsky’s sign). The eroded skin heals slowly, and huge areas of the body eventually are involved. Bacterial superinfection is common.
Complications The most common complications of pemphigus vulgaris arise when the disease process is widespread. Before the advent of corticosteroid and immunosuppressive therapy, patients were very susceptible to secondary bacterial infection. Skin bacteria have relatively easy access to the bullae as they ooze, rupture, and leave denuded areas that are open to the environment. Fluid and electrolyte imbalance results from the loss of both fluid and protein as the bullae rupture. Hypoalbuminemia is common when the disease process includes extensive areas of the body skin surface and mucous membranes.
Management The goals of therapy are to bring the disease under control as rapidly as possible, to prevent loss of serum and the development of secondary infection, and to promote re-epithelization (ie, renewal of epithelial tissue). Corticosteroids are administered in high doses to control the disease and keep the skin free of blisters. The high dosage level is maintained until remission is apparent. In some cases, corticosteroid therapy must be maintained for life. Corticosteroids are administered with or immediately after a meal and may be accompanied by an antacid as prophylaxis against gastric complications. Essential to therapeutic management are daily evaluations of body weight, blood pressure, blood glucose levels, and fluid balance. High-dose corticosteroid therapy has its own serious toxic effects (see Chap. 42). Immunosuppressive agents (eg, azathioprine, cyclophosphamide, gold) may be prescribed to help control the disease and reduce the corticosteroid dose. Plasmapheresis (ie, plasma exchange) temporarily decreases the serum antibody level and has been used with variable success, although it is generally reserved for life-threatening cases.
Medical treatment includes topical corticosteroids for localized eruptions and systemic corticosteroids for widespread involvement. Systemic prednisone may be continued for months, in alternateday doses. The patient needs to understand the implications of long-term corticosteroid therapy, including loss of bone mass, osteoporosis, cataracts, peptic ulcers, psychotic reactions, increased risk for infection, weight gain from fluid retention, and the potential for adrenal suppression.
DERMATITIS HERPETIFORMIS Dermatitis herpetiformis is an intensely pruritic, chronic disease that manifests with small, tense blisters that are distributed symmetrically over the elbows, knees, buttocks, and nape of the neck. It is most common between the ages of 20 and 40 years but can appear at any age. Most patients with dermatitis herpetiformis have a subclinical defect in gluten metabolism.
Management Most patients respond to dapsone (combination of tetracycline and nicotinamide) and to a gluten-free diet. All patients should be screened for glucose-6-phosphate dehydrogenase deficiency, because dapsone can induce severe hemolysis in those with this deficiency. Patients benefit from dietary counseling because the dietary restrictions are lifelong, and a gluten-free diet is often difficult to follow. They need emotional support as they deal with the process of learning new habits and accepting major changes in their life.
HERPES GESTATIONIS Herpes gestationis is a disease that occurs during or shortly after pregnancy. It shares several clinical features with bullous pemphigoid, and despite its name, it has no relation to the herpes virus. This disease is uncommon, with an incidence of approximately 1 case in every 50,000 pregnancies. It appears in the second or third trimester. It begins with urticarial papules on the abdomen and spreads to the trunk and extremities. It usually resolves within a few weeks of delivery but can recur in subsequent pregnancies, with menses, or with the use of oral contraceptives (Odom et al., 2000).
Management Herpes gestationis is best managed with systemic corticosteroids. There is debate about whether there is any risk for fetal morbidity or mortality in babies born to mothers with herpes gestationis. As in other blistering diseases, special attention is required to prevent secondary infection.
Chapter 56 NURSING PROCESS: CARE OF THE PATIENT WITH BLISTERING DISEASES Assessment Patients with blistering disorders may experience significant disability. There is constant itching and possible pain in the denuded areas of skin. There may be drainage from the denuded areas, which may be malodorous. Effective assessment and nursing management become a challenge. Disease activity is monitored clinically by examining the skin for the appearance of new blisters. Areas where healing has occurred may show signs of hyperpigmentation. Particular attention is given to assessing for signs and symptoms of infection.
Diagnosis NURSING DIAGNOSES Based on nursing assessment data, the patient’s major nursing diagnoses may include the following:
• Acute pain of skin and oral cavity related to blistering and erosions
• Impaired skin integrity related to ruptured bullae and de-
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areas of blistering have a characteristic odor that decreases when secondary infection is controlled. After the patient’s skin is bathed, it is dried carefully and dusted liberally with nonirritating powder, which enables the patient to move freely in bed. Fairly large amounts are necessary to keep the patient’s skin from sticking to the sheets. Tape should never be used on the skin because it may produce more blisters. Hypothermia is common, and measures to keep the patient warm and comfortable are priority nursing activities. The nursing management of patients with bullous skin conditions is similar to that for patients with extensive burns (see Chap. 57). REDUCING ANXIETY Attention to the psychological needs of the patient requires listening to the patient, being available, giving expert nursing care, and educating the patient and the family. The patient is encouraged to express freely anxieties, discomfort, and feelings of hopelessness. Arranging for a family member or a close friend to spend more time with the patient can be supportive. When patients receive information about the disease and its treatment, uncertainty and anxiety are reduced, and the patient’s capacity to act on his or her own behalf is enhanced. Referral for psychological counseling may assist the patient in dealing with fears, anxiety, and depression.
nuded areas of the skin
• Anxiety and ineffective coping related to the appearance of •
the skin and no hope of a cure Deficient knowledge about medications and side effects
COLLABORATIVE PROBLEMS/ POTENTIAL COMPLICATIONS Based on the assessment data, potential complications include the following:
• Infection and sepsis related to loss of protective barrier of skin and mucous membranes
• Fluid volume deficit and electrolyte imbalance related to loss of tissue fluids
Planning and Goals The major goals for the patient may include relief of discomfort from lesions, skin healing, reduced anxiety and improved coping capacity, and absence of complications.
Nursing Interventions RELIEVING ORAL DISCOMFORT The patient’s entire oral cavity may be affected with erosions and denuded surfaces. A necrotic slough may develop over these areas, adding to the patient’s discomfort and interfering with food intake. Weight loss and hypoproteinemia may result. Meticulous oral hygiene is important to keep the oral mucosa clean and allow the epithelium to regenerate. Frequent rinsing of the mouth is prescribed to rid the mouth of debris and to soothe ulcerated areas. Commercial mouthwashes are avoided. The lips are kept moist with lanolin, petrolatum, or lip balm. Cool mist therapy helps to humidify environmental air. ENHANCING SKIN INTEGRITY AND RELIEVING DISCOMFORT Cool, wet dressings or baths are protective and soothing. The patient with painful and extensive lesions should be premedicated with analgesics before skin care is initiated. Patients with large
MONITORING AND MANAGING POTENTIAL COMPLICATIONS Infection and Sepsis The patient is susceptible to infection because the barrier function of the skin is compromised. Bullae are also susceptible to infection, and sepsis may follow. The skin is cleaned to remove debris and dead skin and to prevent infection. Secondary infection may be accompanied by an offensive odor from skin or oral lesions. C. albicans of the mouth (ie, thrush) commonly affects patients receiving high-dose corticosteroid therapy. The oral cavity is inspected daily, and any changes are reported. Oral lesions are slow to heal. Infection is the leading cause of death in patients with blistering diseases. Particular attention is given to assessment for signs and symptoms of local and systemic infection. Seemingly trivial complaints or minimal changes are investigated, because corticosteroids can mask or alter typical signs and symptoms of infection. The patient’s vital signs are taken, and temperature fluctuations are monitored. The patient is observed for chills, and all secretions and excretions are monitored for changes suggesting infection. Results of culture and sensitivity tests are monitored. Antimicrobial agents are administered as prescribed, and response to treatment is assessed. Health care personnel must perform effective hand hygiene and wear gloves. In the hospitalized patient, environmental contamination is reduced as much as possible. Protective isolation measures and standard precautions are warranted. Fluid and Electrolyte Imbalance Extensive denudation of the skin leads to fluid and electrolyte imbalance because of significant loss of fluids and sodium chloride from the skin. This sodium chloride loss is responsible for many of the systemic symptoms associated with the disease and is treated by intravenous administration of saline solution. A large amount of protein and blood is lost from the denuded skin areas. Blood component therapy may be prescribed to maintain the blood volume, hemoglobin level, and plasma protein
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concentration. Serum albumin, protein, hemoglobin, and hematocrit values are monitored. The patient is encouraged to maintain adequate oral fluid intake. Cool, nonirritating fluids are encouraged to maintain hydration. Small, frequent meals or snacks of high-protein, highcalorie foods (eg, Ensure, Sustacal, eggnog, milkshakes) help maintain nutritional status. Parenteral nutrition is considered if the patient cannot eat an adequate diet.
Evaluation EXPECTED PATIENT OUTCOMES Expected patient outcomes may include the following: 1. Achieves relief from pain of oral lesions a. Identifies therapies that reduce pain b. Uses mouthwashes and anesthetic or antiseptic aerosol mouth spray c. Drinks chilled fluids at 2-hour intervals 2. Achieves skin healing a. States purpose of therapeutic regimen b. Cooperates with soaks and bath regimen c. Reminds caregivers to use liberal amounts of nonirritating powder on bed linens 3. Is less anxious and better able to cope a. Verbalizes concerns about condition, self, and relationships with others b. Participates in self-care 4. Experiences no complications a. Has cultures from bullae, skin, and orifices that are negative for pathogenic organisms b. Has no purulent drainage c. Shows signs that skin is clearing d. Has normal temperature e. Keeps intake record to ensure adequate fluid intake and normal fluid and electrolyte balance f. Verbalizes the rationale for intravenous infusion therapy g. Has urine output within normal limits h. Has serum chemistry and hemoglobin and hematocrit values within normal limits
TOXIC EPIDERMAL NECROLYSIS AND STEVENS-JOHNSON SYNDROME Toxic epidermal necrolysis (TEN) and Stevens-Johnson syndrome (SJS) are potentially fatal skin disorders and the most severe form of erythema multiforme. The mortality rate from TEN approaches 30%. Both conditions are triggered by a reaction to medications or result from a viral infection. Antibiotics, antiseizure agents, butazones, and sulfonamides are the most frequent medications implicated in TEN and SJS (Odom et al., 2000).
Clinical Manifestations TEN and SJS are characterized initially by conjunctival burning or itching, cutaneous tenderness, fever, cough, sore throat, headache, extreme malaise, and myalgias (ie, aches and pains). These signs are followed by a rapid onset of erythema involving much of the skin surface and mucous membranes, including the oral mucosa, conjunctiva, and genitalia. In severe cases of mucosal involvement, there may be danger of damage to the larynx, bronchi, and esophagus from ulcerations. Large, flaccid bullae develop in
some areas; in other areas, large sheets of epidermis are shed, exposing the underlying dermis. Fingernails, toenails, eyebrows, and eyelashes may be shed along with the surrounding epidermis. The skin is excruciatingly tender, and the loss of skin leaves a weeping surface similar to that of a total-body, partial-thickness burn; hence the condition is also referred to as scalded skin syndrome. These conditions occur in all ages and both genders. The incidence is increased in older people because of their use of many medications. People with HIV, particularly those with acquired immunodeficiency syndrome (AIDS), and others who are immunocompromised are at higher risk for SJS and TEN. Although the incidence of TEN and SJS in the general population is about 3 cases per 1 million person-years, the risk associated with sulfonamides in HIV-positive individuals may approach 1 case per 1000 (Odom et al., 2000). Most patients with TEN have an abnormal metabolism of the culprit medication, and the mechanism leading to TEN seems to be a cell-mediated cytotoxic reaction (Wolkenstein, 2000).
Complications Sepsis and keratoconjunctivitis are complications of TEN and SJS. Unrecognized and untreated sepsis can be life-threatening. Keratoconjunctivitis can impair vision and result in conjunctival retraction, scarring, and corneal lesions.
Assessment and Diagnostic Findings Histologic studies of frozen skin cells from a fresh lesion and cytodiagnosis of collections of cellular material from a freshly denuded area are performed. A history of ingestion of medications known to precipitate TEN or SJS may confirm medication reaction as the underlying cause. Immunofluorescent studies may be performed to detect atypical epidermal autoantibodies. A genetic predisposition to erythema multiforme has been suggested but is not confirmed for all cases.
Medical Management The goals of treatment include control of fluid and electrolyte balance, prevention of sepsis, and prevention of ophthalmic complications. Supportive care is the mainstay of treatment. All nonessential medications are discontinued immediately. If possible, the patient is treated in a regional burn center, because aggressive treatment similar to that for severe burns is required. Skin loss may approach 100% of the total body surface area. Surgical débridement or hydrotherapy in a Hubbard tank (ie, large, steel tub) may be performed to remove involved skin. Tissue samples from the nasopharynx, eyes, ears, blood, urine, skin, and unruptured blisters are obtained for culture to identify pathogenic organisms. Intravenous fluids are prescribed to maintain fluid and electrolyte balance, especially in the patient who has severe mucosal involvement and who cannot easily take oral nourishment. Because an indwelling intravenous catheter may be a site of infection, fluid replacement is carried out by nasogastric tube and then orally as soon as possible. Initial treatment with systemic corticosteroids is controversial. Some experts argue for early high-dose corticosteroid treatment. However, in most cases, the risk for infection, the complication of fluid and electrolyte imbalance, the delay in the healing process, and the difficulty in initiating oral corticosteroids early in the course of the disease outweigh the perceived benefits. In patients
Chapter 56 with TEN thought to result from a medication reaction, corticosteroids may be administered; however, the patients should be closely monitored for the previously stated adverse effects. One report stated that intravenous administration of immunoglobulin (IVIG) to 10 patients led to improvement within 48 hours and skin healing within 1 week. This response is dramatically better than that obtained with immunosuppressives, and IVIG may soon become the treatment of choice (Rutter & Luger, 2001). Protecting the skin with topical agents is crucial. Various topical antibacterial and anesthetic agents are used to prevent wound sepsis and to assist with pain management. Systemic antibiotic therapy is used with extreme caution. Temporary biologic dressings (eg, pigskin, amniotic membrane) or plastic semipermeable dressings (eg, Vigilon) may be used to reduce pain, decrease evaporation, and prevent secondary infection until the epithelium regenerates. Meticulous oropharyngeal and eye care is essential when there is severe involvement of the mucous membranes and the eyes.
NURSING PROCESS: CARE OF THE PATIENT WITH TOXIC EPIDERMAL NECROLYSIS Assessment A careful inspection of the skin is made, including its appearance and the extent of involvement. The normal skin is closely observed to determine if new areas of blisters are developing. Seepage from blisters is monitored for amount, color, and odor. Inspection of the oral cavity for blistering and erosive lesions is performed daily; the patient is assessed daily for itching, burning, and dryness of the eyes. The patient’s ability to swallow and drink fluids, as well as speak normally, is determined. The patient’s vital signs are monitored, and special attention is given to the presence and character of fever and the respiratory rate, depth, rhythm, and cough. The characteristics and amount of respiratory secretions are reviewed. Assessment for high fever, tachycardia, and extreme weakness and fatigue is essential, because these factors indicate the process of epidermal necrosis, increased metabolic needs, and possible gastrointestinal and respiratory mucosal sloughing. Urine volume, specific gravity, and color are monitored. The insertion sites of intravenous lines are inspected for signs of local infection. Daily body weights are recorded. The patient is asked to describe fatigue and pain levels. An attempt is made to evaluate the patient’s level of anxiety. The patient’s basic coping mechanisms are assessed, and effective coping strategies are identified.
Diagnosis NURSING DIAGNOSES Based on the assessment data, the patient’s major nursing diagnoses may include the following:
• Impaired tissue integrity (ie, oral, eye, and skin) related to • • •
epidermal shedding Deficient fluid volume and electrolyte losses related to loss of fluids from denuded skin Risk for imbalanced body temperature (ie, hypothermia) related to heat loss secondary to skin loss Acute pain related to denuded skin, oral lesions, and possible infection
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• Anxiety related to the physical appearance of the skin and prognosis
COLLABORATIVE PROBLEMS/ POTENTIAL COMPLICATIONS Based on the assessment data, potential complications include the following:
• Sepsis • Conjunctival retraction, scars, and corneal lesions Planning and Goals The major goals for the patient may include skin and oral tissue healing, fluid balance, prevention of heat loss, relief of pain, reduced anxiety, and absence of complications.
Nursing Interventions MAINTAINING SKIN AND MUCOUS MEMBRANE INTEGRITY The local care of the skin is an important area of nursing management. The skin denudes easily, even when the patient is lifted and turned; it may be necessary to place the patient on a circular turning frame. The nurse applies the prescribed topical agents that reduce the bacterial population of the wound surface. Warm compresses, if prescribed, should be applied gently to denuded areas. The topical antibacterial agent may be used in conjunction with hydrotherapy in a tank, bathtub, or shower. The nurse monitors the patient’s condition during the treatment and encourages the patient to exercise the extremities during hydrotherapy. The painful oral lesions make oral hygiene difficult. Careful oral hygiene is performed to keep the oral mucosa clean. Prescribed mouthwashes, anesthetics, or coating agents are used frequently to rid the mouth of debris, soothe ulcerative areas, and control foul mouth odor. The oral cavity is inspected several times each day, and any changes are documented and reported. Petrolatum or a prescribed ointment is applied to the lips. ATTAINING FLUID BALANCE The vital signs, urine output, and sensorium are observed for indications of hypovolemia. Mental changes from fluid and electrolyte imbalance, sensory overload, or sensory deprivation may occur. Laboratory test results are evaluated, and abnormal results are reported. The patient is weighed daily (with a bed scale if necessary). The nurse regulates intravenous fluids at prescribed infusion rates and assesses for systemic (ie, overinfusion or underinfusion) and local (eg, infection) complications. Oral lesions may result in dysphagia, making tube feeding or parenteral nutrition necessary. Prescribed enteral nourishment or enteral supplements can be administered by tube feeding until oral ingestion can be tolerated. A daily calorie count and accurate recording of all intake and output are essential. PREVENTING HYPOTHERMIA The patient with TEN is prone to chilling. Dehydration may be made worse by exposing the denuded skin to a continuous current of warm air. The patient is usually sensitive to room temperature changes. Measures implemented for a burn patient, such as cotton blankets, ceiling-mounted heat lamps, and heat shields, are useful in maintaining body temperature. To minimize shivering and heat loss, the nurse should work rapidly and efficiently
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when large wounds are exposed for wound care. The patient’s temperature is monitored frequently. RELIEVING PAIN The nurse assesses the patient’s pain, its characteristics, any factors that influence the pain, and the patient’s behavioral responses. Prescribed analgesics are administered, and the nurse documents pain relief and any side effects. Analgesics are administered before painful treatments are performed. Providing thorough explanations and speaking calmly to the patient during treatments can allay the anxiety that may intensify pain. Offering emotional support and reassurance and implementing measures that promote rest and sleep are basic in achieving pain control. As the pain diminishes and the patient has more physical and emotional energy, self-management techniques for pain relief, such as progressive muscle relaxation and imagery, may be taught. REDUCING ANXIETY Because the lifestyle of patients with TEN has been abruptly changed to one of complete dependence, an assessment of their emotional state may reveal anxiety, depression, and fear of dying. Patients can be reassured that these reactions are normal. They also need nursing support, honest communication, and hope that their situation can improve. They are encouraged to express their feelings to someone they trust. Listening to their concerns and being readily available with skillful and compassionate care are important anxiety-relieving interventions. Emotional support by a psychiatric nurse, chaplain, psychologist, or psychiatrist may be helpful to promote coping during the long recovery period.
Evaluation EXPECTED PATIENT OUTCOMES Expected patient outcomes may include the following: 1. Achieves increasing skin and oral tissue healing a. Demonstrates areas of healing skin b. Swallows fluids and speaks clearly 2. Attains fluid balance a. Demonstrates laboratory values within normal ranges b. Maintains urine volume and specific gravity within acceptable range c. Shows stable vital signs d. Increases intake of oral fluids without discomfort e. Gains weight, if appropriate 3. Attains thermoregulation a. Registers body temperature within normal range b. Reports no chills 4. Achieves pain relief a. Uses analgesics as prescribed b. Uses self-management techniques for relief of pain 5. Appears less anxious a. Discusses concerns freely b. Sleeps for progressively longer periods 6. Absence of complications, such as sepsis and impaired vision a. Body temperature within normal range b. Laboratory values within normal ranges c. Has no abnormal discharges or signs of infection d. Continues to see objects at baseline acuity level e. Shows no signs of keratoconjunctivitis
MONITORING AND MANAGING POTENTIAL COMPLICATIONS
Ulcerations
Sepsis The major cause of death from TEN is infection, and the most common sites of infection are the skin and mucosal surfaces, lungs, and blood. The organisms most often involved are S. aureus, Pseudomonas, Klebsiella, Escherichia coli, Serratia, and Candida. Monitoring vital signs closely and noticing changes in respiratory, renal, and gastrointestinal function may quickly detect the beginning of an infection. Strict asepsis is always maintained during routine skin care measures. Hand hygiene and wearing sterile gloves when carrying out procedures are necessary. When the condition involves a large portion of the body, the patient should be in a private room to prevent possible cross-infection from other patients. Visitors should wear protective garments and wash their hands before and after coming into contact with the patient. People with any infectious disease should not visit the patient until they are no longer a danger to the patient.
Superficial loss of surface tissue as a result of death of the cells is called an ulceration. A simple ulcer, such as the kind found in a small, superficial, partial-thickness burn, tends to heal by granulation (ie, new tissue granules) if kept clean and protected from injury. If it is exposed to the air, the serum that escapes will dry and form a scab, under which the epithelial cells will grow and cover the surface completely. Certain diseases cause characteristic ulcers; tuberculous ulcers and syphilitic ulcers are examples. Ulcers related to problems with arterial circulation are seen in patients with peripheral vascular disease, arteriosclerosis, Raynaud’s disease, and frostbite. In these patients, treatment of the ulcers is concurrent with treatment of the arterial disease (see Chap. 31). Nursing management includes the use of the dressings discussed at the beginning of this chapter. If nursing interventions are instituted early in the progression of an ulcer, the condition can often be effectively improved. Surgical amputation of an affected limb is a last resort. Pressure ulcers involve breakdown of the skin due to prolonged pressure and insufficient blood supply, usually at bony prominences. Information about these ulcers is presented in chapter 11.
Conjunctival Retraction, Scars, and Corneal Lesions The eyes are inspected daily for signs of itching, burning, and dryness, which may indicate progression often to keratoconjunctivitis, the principal eye complication. Applying a cool, damp cloth over the eyes may relieve burning sensations. The eyes are kept clean and observed for signs of discharge or discomfort, and the progression of symptoms is documented and reported. Administering an eye lubricant, when prescribed, may alleviate dryness and prevent corneal abrasion. Using eye patches or reminding the patient to blink periodically may also counteract dryness. The patient is instructed to avoid rubbing the eyes or putting any medication into the eyes that has not been prescribed or approved by the physician.
Benign Tumors of the Skin CYSTS Cysts of the skin are epithelium-lined cavities that contain fluid or solid material. Epidermal cysts (ie, epidermoid cysts) occur frequently and may be described as slow-growing, firm, elevated tumors found most frequently on the face, neck, upper chest, and back. Removal of the cysts provides a cure.
Chapter 56 Pilar cysts (ie, trichilemmal cysts), formerly called sebaceous cysts, are most frequently found on the scalp. They originate from the middle portion of the hair follicle and from the cells of the outer hair root sheath. The treatment is surgical removal.
ACTINIC AND SEBORRHEIC KERATOSES Seborrheic keratoses are benign, wartlike lesions of various sizes and colors, ranging from light tan to black. They are usually located on the face, shoulders, chest, and back and are the most common skin tumors seen in middle-aged and elderly people. They may be cosmetically unacceptable to the patient. A black keratosis may be erroneously diagnosed as malignant melanoma. The treatment is removal of the tumor tissue by excision, electrodesiccation and curettage, or application of carbon dioxide or liquid nitrogen. However, there is no harm in allowing these growths to remain, because there is no medical significance to their presence. Actinic keratoses are premalignant skin lesions that develop in chronically sun-exposed areas of the body. They appear as rough, scaly patches with underlying erythema. A small percentage of these lesions gradually transform into cutaneous squamous cell carcinoma; they are usually removed by cryotherapy or shave excision.
VERRUCAE: WARTS Warts are common, benign skin tumors caused by infection with the human papillomavirus, which belongs to the DNA virus group. All age groups may be affected, but the condition occurs most frequently between ages 12 and 16 years. There are many types of warts. As a rule, warts are asymptomatic, except when they occur on weight-bearing areas, such as the soles of the feet. They may be treated with locally applied laser therapy, liquid nitrogen, salicylic acid plasters, or electrodesiccation (ie, destruction of skin lesions by monopolar high-frequency electric current). Warts occurring on the genitalia and perianal areas are known as condylomata acuminata. They may be transmitted sexually and are treated with liquid nitrogen, cryosurgery, electrosurgery, topically applied trichloracetic acid, and curettage. Condylomata (see Chapter 47) that affect the uterine cervix predispose the patient to cervical cancer.
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tain hair. Most pigmented nevi are harmless lesions. However, in rare cases, malignant changes occur, and a melanoma develops at the site of the nevus. Some authorities believe that all congenital moles should be removed, because they may have a higher incidence of malignant change. However, depending on the quantity and location, this may be impractical. Nevi that show a change in color or size or become symptomatic (eg, itch) or develop irregular borders should be removed to determine if malignant changes have occurred. Moles that occur in unusual places should be examined carefully for any irregularity and for notching of the border and variation in color. Early melanomas may display some redness and irritation and areas of bluish pigmentation where the pigment-containing cells have spread deeper into the skin. Late melanomas have areas of paler color, where pigment cells have stopped producing melanin. Nevi larger than 1 cm should be examined carefully. Excised nevi should be examined histologically.
KELOIDS Keloids are benign overgrowths of fibrous tissue at the site of a scar or trauma. They appear to be more common among darkskinned people. Keloids are asymptomatic but may cause disfigurement and cosmetic concern. The treatment, which is not always satisfactory, consists of surgical excision, intralesional corticosteroid therapy, and radiation.
DERMATOFIBROMA A dermatofibroma is a common, benign tumor of connective tissue that occurs predominantly on the extremities. It is a firm, dome-shaped papule or nodule that may be skin colored or pinkish brown. Excisional biopsy is the recommended method of treatment.
NEUROFIBROMATOSIS: VON RECKLINGHAUSEN’S DISEASE Neurofibromatosis is a hereditary condition manifested by pigmented patches (ie, café-au-lait macules), axillary freckling, and cutaneous neurofibromas that vary in size. Developmental changes may occur in the nervous system, muscles, and bone. Malignant degeneration of the neurofibromas occurs in some patients.
ANGIOMAS Angiomas are benign vascular tumors that involve the skin and the subcutaneous tissues. They are present at birth and may occur as flat, violet-red patches (ie, port-wine angiomas) or as raised, bright-red, nodular lesions (ie, strawberry angiomas). The latter tend to involute spontaneously within the first few years of life, but port-wine angiomas usually persist indefinitely. Most patients use masking cosmetics (ie, Covermark or Dermablend) to camouflage the lesion. The argon laser is being used on various angiomas with some success. Treatment of strawberry angiomas is more successful if undertaken as soon after birth as possible (Odom et al., 2000).
PIGMENTED NEVI: MOLES Moles are common skin tumors of various sizes and shades, ranging from yellowish brown to black. They may be flat, macular lesions or elevated papules or nodules that occasionally con-
Malignant Tumors of the Skin: Skin Cancer Skin cancer is the most common cancer in the United States. If the incidence continues at the present rate, an estimated one of eight fair-skinned Americans will develop skin cancer, especially basal cell carcinoma (Chart 56-5). Because the skin is easily inspected, skin cancer is readily seen and detected and is the most successfully treated type of cancer (Odom et al., 2000). Exposure to the sun is the leading cause of skin cancer; incidence is related to the total amount of exposure to the sun. Sun damage is cumulative, and harmful effects may be severe by age 20 years. The increase in skin cancer probably reflects changing lifestyles and the emphasis on sunbathing and related activities in light of changes in the environment, such as holes in the Earth’s ozone layer. Protective measures should be used throughout life, and nurses need to inform patients about risk factors associated with skin cancer.
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Chart 56-5
Risk Factors for Skin Cancer Changes in the ozone layer from the effects of worldwide industrial air pollutants, such as chlorofluorocarbons, have prompted concern that the incidence of skin cancers, especially malignant melanoma, will increase. The ozone layer, a stratospheric blanket of bluish, explosive gas formed by the sun’s ultraviolet radiation, varies in depth with the seasons and is thickest at the North and South Poles and thinnest at the equator. Scientists believe that it helps protect the earth from the effects of solar ultraviolet radiation. Proponents of this theory predict an increase in skin cancers as a consequence of changes in the ozone layer. Other skin cancer risk factors follow: Fair-skinned, fair-haired, blue-eyed people, particularly those of Celtic origin, with insufficient skin pigmentation to protect underlying tissues People who sustain sunburn and who do not tan Long-time sun exposure (farmers, fishermen, construction workers) Exposure to chemical pollutants (industrial workers in arsenic, nitrates, coal, tar and pitch, oils and paraffins) Sun-damaged skin (elderly people) History of x-ray therapy for acne or benign lesions Scars from severe burns Chronic skin irritations Immunosuppression Genetic factors
BASAL CELL AND SQUAMOUS CELL CARCINOMA The most common types of skin cancer are basal cell carcinoma (BCC) and squamous cell (epidermoid) carcinoma (SCC). The third most common type, malignant melanoma, is discussed separately. Skin cancer is diagnosed by biopsy and histologic evaluation.
Clinical Manifestations BCC is the most common type of skin cancer. It generally appears on sun-exposed areas of the body and is more prevalent in regions where the population is subjected to intense and extensive exposure to the sun. The incidence is proportional to the age of the patient (average age of 60 years) and the total amount of sun exposure, and it is inversely proportional to the amount of melanin in the skin. BCC usually begins as a small, waxy nodule with rolled, translucent, pearly borders; telangiectatic vessels may be present. As it grows, it undergoes central ulceration and sometimes crusting (Fig. 56-6). The tumors appear most frequently on the face. BCC is characterized by invasion and erosion of contiguous (adjoining) tissues. It rarely metastasizes, but recurrence is common. However, a neglected lesion can result in the loss of a nose, an ear, or a lip. Other variants of BCC may appear as shiny, flat, gray or yellowish plaques. SCC is a malignant proliferation arising from the epidermis. Although it usually appears on sun-damaged skin, it may arise from normal skin or from preexisting skin lesions. It is of greater concern than BCC because it is a truly invasive carcinoma, metastasizing by the blood or lymphatic system. Metastases account for 75% of deaths from SCC. The lesions may be primary, arising on the skin and mucous membranes, or
FIGURE 56-6
Basal cell carcinoma (left ) and squamous cell carcinoma (right). Reprinted by permission from New England Journal of Medicine, 326, 169–170, 1992.
they may develop from a precancerous condition, such as actinic keratosis (ie, lesions occurring in sun-exposed areas), leukoplakia (ie, premalignant lesion of the mucous membrane), or scarred or ulcerated lesions. SCC appears as a rough, thickened, scaly tumor that may be asymptomatic or may involve bleeding (see Fig. 56-6). The border of an SCC lesion may be wider, more infiltrated, and more inflammatory than that of a BCC lesion. Secondary infection can occur. Exposed areas, especially of the upper extremities and of the face, lower lip, ears, nose, and forehead, are common sites (Odom et al., 2000).
Prognosis The prognosis for BCC is usually good. Tumors remain localized, and although some require wide excision with resultant disfigurement, the risk for death from BCC is low. The prognosis for SCC depends on the incidence of metastases, which is related to the histologic type and the level or depth of invasion. Usually, tumors arising in sun-damaged areas are less invasive and rarely cause death, whereas SCC that arises without a history of sun or arsenic exposure or scar formation appears to have a greater chance for spread. Regional lymph nodes should be evaluated for metastases (Odom et al., 2000).
Medical Management The goal of treatment is to eradicate the tumor. The treatment method depends on the tumor location; the cell type, location, and depth; the cosmetic desires of the patient; the history of previous treatment; whether the tumor is invasive, and whether metastatic nodes are present. The management of BCC and SCC includes surgical excision, Mohs’ micrographic surgery, electrosurgery, cryosurgery, and radiation therapy. SURGICAL MANAGEMENT The primary goal is to remove the tumor entirely. The best way to maintain cosmetic appearance is to place the incision properly along natural skin tension lines and natural anatomic body lines. In this way, scars are less noticeable. The size of the incision depends on the tumor size and location but usually involves a length-to-width ratio of 3⬊1.
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The adequacy of the surgical excision is verified by microscopic evaluation of sections of the specimen. When the tumor is large, reconstructive surgery with use of a skin flap or skin grafting may be required. The incision is closed in layers to enhance cosmetic effect. A pressure dressing applied over the wound provides support. Infection after a simple excision is uncommon if proper surgical asepsis is maintained.
Nursing Management
Mohs’ Micrographic Surgery. Mohs’ micrographic surgery is the technique that is most accurate and that best conserves normal tissue. When the surgical technique was introduced, the excision followed an application of zinc chloride paste to the tumor, but Mohs’ surgery is now performed without the initial chemosurgery component. The procedure removes the tumor layer by layer. The first layer excised includes all evident tumor and a small margin of normal-appearing tissue. The specimen is frozen and analyzed by section to determine if all the tumor has been removed. If not, additional layers of tissue are shaved and examined until all tissue margins are tumor free. In this manner, only the tumor and a safe, normal-tissue margin are removed. Mohs’ surgery is the recommended tissue-sparing procedure, with cure rates for BCC and SCC approaching 99%. It is the treatment of choice and the most effective for tumors around the eyes, nose, upper lip, and auricular and periauricular areas (Odom et al., 2000).
Teaching Patients Self-Care. The wound is usually covered with a dressing to protect the site from physical trauma, external irritants, and contaminants. The patient is advised when to report for a dressing change or is given written and verbal information on how to change dressings, including the type of dressing to purchase, how to remove dressings and apply fresh ones, and the importance of hand washing before and after the procedure. The patient is advised to watch for excessive bleeding and tight dressings that compromise circulation. If the lesion is in the perioral area, the patient is instructed to drink liquids through a straw and limit talking and facial movement. Dental work should be avoided until the area is completely healed. After the sutures are removed, an emollient cream may be used to help reduce dryness. Applying a sunscreen over the wound is advised to prevent postoperative hyperpigmentation if the patient spends time outdoors.
Electrosurgery. Electrosurgery is the destruction or removal of tissue by electrical energy. The current is converted to heat, which then passes to the tissue from a cold electrode. Electrosurgery may be preceded by curettage (ie, excising the skin tumor by scraping its surface with a curette). Electrodesiccation is then implemented to achieve hemostasis and to destroy any viable malignant cells at the base of the wound or along its edges. Electrodesiccation is useful for lesions smaller than 1 to 2 cm (0.4 to 0.8 in) in diameter. This method takes advantage of the fact that the tumor in each instance is softer than surrounding skin and therefore can be outlined by a curette, which “feels” the extent of the tumor. The tumor is removed and the base cauterized. The process is repeated twice. Usually, healing occurs within a month. Cryosurgery. Cryosurgery destroys the tumor by deep freezing the tissue. A thermocouple needle apparatus is inserted into the skin, and liquid nitrogen is directed to the center of the tumor until the tumor base is −40°C to −60°C. Liquid nitrogen has the lowest boiling point of all cryogens tried, is inexpensive, and is easy to obtain. The tumor tissue is frozen, allowed to thaw, and then refrozen. The site thaws naturally and then becomes gelatinous and heals spontaneously. Swelling and edema follow the freezing. The appearance of the lesion varies. Normal healing, which may take 4 to 6 weeks, occurs faster in areas with a good blood supply. RADIATION THERAPY Radiation therapy is frequently performed for cancer of the eyelid, the tip of the nose, and areas in or near vital structures (eg, facial nerve). It is reserved for older patients, because x-ray changes may be seen after 5 to 10 years, and malignant changes in scars may be induced by irradiation 15 to 30 years later. The patient should be informed that the skin may become red and blistered. A bland skin ointment prescribed by the physician may be applied to relieve discomfort. The patient should also be cautioned to avoid exposure to the sun.
Because many skin cancers are removed by excision, patients are usually treated in outpatient surgical units. The role of the nurse is to teach the patient about prevention of skin cancer and about self-care after treatment (Chart 56-6). PROMOTING HOME AND COMMUNITY-BASED CARE
Chart 56-6 Health Promotion: Preventing Skin Cancer Because skin cancer rates are rising, taking preventive measures such as the ones outlined below may help individuals avoid increasing their skin cancer risk. • Do not try to tan if your skin burns easily, never tans, or tans poorly. • Avoid unnecessary exposure to the sun, especially during the time of day when ultraviolet radiation (sunlight) is most intense (10 AM to 3 PM). • Avoid sunburn. • Apply sunscreen when in the sun; sunscreens block harmful sun rays. • Use a sunscreen with an SPF of 15 or higher. Sunscreens are rated in strength from 4 (weakest) to 50 (strongest). The SPF indicates the solar protection factor, or how much longer you can stay in the sun before getting burned. Look for sunscreens that protect against both ultraviolet-A (UVA) and ultraviolet-B (UVB) light. • Reapply water-resistant sunscreens after swimming, if heavily sweating, and every 2 to 3 hours during prolonged periods of sun exposure. • Avoid oils. Applied before or during sun exposure, oils do not protect against sunlight or sun damage. • Use a lip balm that contains a sunscreen with the highest SPF number. • Wear protective clothing, such as a broad-brimmed hat and long sleeves. • Remember that up to 50% of ultraviolet rays can penetrate loosely woven clothing. • Remember that ultraviolet light can penetrate a cloud cover, and a sunburn can still occur. • Do not use sun lamps for indoor tanning, and avoid commercial tanning booths. These rays are just as harmful. • Teach children to avoid all but modest sun exposure and to use a sunscreen regularly for lifelong protection.
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Follow-up examinations should be at regular intervals, usually every 3 months for a year, and should include palpation of the adjacent lymph nodes. The patient should also be instructed to seek treatment for any moles that are subject to repeated friction and irritation, and to watch for indications of potential malignancy in moles as described previously. The importance of lifelong follow-up evaluations should be emphasized.
Chart 56-7
Risk Factors for Malignant Melanoma • Fair-skinned or freckled, blue-eyed, light-haired people of Celtic or Scandinavian origin
• People who burn and do not tan or who have a significant history of severe sunburn
• Environmental exposure to intense sunlight (older Americans Teaching About Prevention. Studies show that regular daily use of a sunscreen with a solar protection factor (SPF) of at least 15 can reduce the recurrence of skin cancer by as much as 40%. The sunscreen should be applied to head, neck, arms, and hands every morning at least 30 minutes before leaving the house and reapplied every 4 hours if the skin perspires. Discretionary application (ie, applied only when sun exposure is anticipated) has not shown the same preventive response (Barton, 2001).
retiring to the southwestern United States appear to have a higher incidence) • History of melanoma (personal or family) • Skin with giant congenital nevi
The absence of this gene can be identified in melanoma-prone families (Piepkorn, 2000).
MALIGNANT MELANOMA A malignant melanoma is a cancerous neoplasm in which atypical melanocytes (ie, pigment cells) are present in the epidermis and the dermis (and sometimes the subcutaneous cells). It is the most lethal of all the skin cancers and is responsible for about 2% of all cancer deaths (Odom et al., 2000). It can occur in one of several forms: superficial spreading melanoma, lentigo-maligna melanoma, nodular melanoma, and acral-lentiginous melanoma. These types have specific clinical and histologic features as well as different biologic behaviors. Most melanomas arise from cutaneous epidermal melanocytes, but some appear in preexisting nevi (ie, moles) in the skin or develop in the uveal tract of the eye. Melanomas occasionally appear simultaneously with cancer of other organs. The worldwide incidence of melanoma doubles every 10 years, a rise that is probably related to increased recreational sun exposure and better methods of early detection. Peak incidence occurs between ages 20 and 45. The incidence of melanoma is increasing faster than that of almost any other cancer, and the mortality rate is increasing faster than that of any other cancer except lung cancer. The estimated number of new cases in 2002 is 53,600 and the number of deaths is 7400 (American Cancer Society, 2002).
Risk Factors The cause of malignant melanoma is unknown, but ultraviolet rays are strongly suspected, based on indirect evidence such as the increased incidence of melanoma in countries near the equator and in people younger than age 30 who have used a tanning bed more than 10 times per year. In general, 1 in 100 Caucasians will get melanoma every year. Up to 10% of melanoma patients are members of melanoma-prone families who have multiple changing moles (ie, dysplastic nevi) that are susceptible to malignant transformation. Patients with dysplastic nevus syndrome have been found to have unusual moles, larger and more numerous moles, lesions with irregular outlines, and pigmentation located all over the skin. Microscopic examination of dysplastic moles shows disordered, faulty growth. Chart 56-7 lists risk factors for malignant melanoma. Research has identified a gene that resides on chromosome 9p, the absence of which increases the likelihood that potentially mutagenic DNA damage will escape repair before cell division.
Clinical Manifestations Superficial spreading melanoma occurs anywhere on the body and is the most common form of melanoma. It usually affects middle-aged people and occurs most frequently on the trunk and lower extremities. The lesion tends to be circular, with irregular outer portions. The margins of the lesion may be flat or elevated and palpable (Fig. 56-7). This type of melanoma may appear in a combination of colors, with hues of tan, brown, and black mixed with gray, blue-black, or white. Sometimes a dull pink rose color can be seen in a small area within the lesion. LENTIGO-MALIGNA MELANOMAS Lentigo-maligna melanomas are slowly evolving, pigmented lesions that occur on exposed skin areas, especially the dorsum of the hand, the head, and the neck in elderly people. Often, the lesions are present for many years before they are examined by a physician. They first appear as tan, flat lesions, but in time, they undergo changes in size and color. NODULAR MELANOMA Nodular melanoma is a spherical, blueberry-like nodule with a relatively smooth surface and a relatively uniform, blue-black color (see Fig. 56-7). It may be dome shaped with a smooth surface. It may have other shadings of red, gray, or purple. Sometimes, nodular melanomas appear as irregularly shaped plaques.
FIGURE 56-7 Two forms of malignant melanoma: superficial spreading (left) and nodular (right). From Bickley, L. S., & Szilagyi, P. (2003). Bates’ guide to physical examination and history taking (8th ed.). Philadelphia: Lippincott Williams & Wilkins.
Chapter 56 The patient may describe this as a blood blister that fails to resolve. A nodular melanoma invades directly into adjacent dermis (ie, vertical growth) and therefore has a poorer prognosis. ACRAL-LENTIGINOUS MELANOMA Acral-lentiginous melanoma occurs in areas not excessively exposed to sunlight and where hair follicles are absent. It is found on the palms of the hands, on the soles, in the nail beds, and in the mucous membranes in dark-skinned people. These melanomas appear as irregular, pigmented macules that develop nodules. They may become invasive early.
Assessment and Diagnostic Findings Biopsy results confirm the diagnosis of melanoma. An excisional biopsy specimen provides histologic information on the type, level of invasion, and thickness of the lesion. An excisional biopsy specimen that includes a 1-cm margin of normal tissue and a portion of underlying subcutaneous fatty tissue is sufficient for staging a melanoma in situ or an early, noninvasive melanoma. Incisional biopsy should be performed when the suspicious lesion is too large to be removed safely without extensive scarring. Biopsy specimens obtained by shaving, curettage, or needle aspiration are not considered reliable histologic proof of disease. A thorough history and physical examination should include a meticulous skin examination and palpation of regional lymph nodes that drain the lesional area. Because melanoma occurs in families, a positive family history of melanoma is investigated so that first-degree relatives, who may be at high risk for melanoma, can be evaluated for atypical lesions. After the diagnosis of melanoma has been confirmed, a chest x-ray, complete blood cell count, liver function tests, and radionuclide or computed tomography scans are usually ordered to stage the extent of disease.
Prognosis The prognosis for long-term (5-year) survival is considered poor when the lesion is more than 1.5 mm thick or there is regional lymph node involvement. A person with a thin lesion and no lymph node involvement has a 3% chance of developing metastases and a 95% chance of surviving 5 years. If regional lymph nodes are involved, there is a 20% to 50% chance of surviving 5 years. Patients with melanoma on the hand, foot, or scalp have a better prognosis; those with lesions on the torso have an increased chance of metastases to the bone, liver, lungs, spleen, and central nervous system. Men and elderly patients also have poor prognoses (Demis, 1998).
Medical Management Treatment depends on the level of invasion and the depth of the lesion. Surgical excision is the treatment of choice for small, superficial lesions. Deeper lesions require wide local excision, after which skin grafting may be needed. Regional lymph node dissection is commonly performed to rule out metastasis, although new surgical approaches call for only sentinel node biopsy. This technique is used to sample the nodes nearest the tumor and spares the patient the long-term sequelae of extensive removal of lymph nodes if the sample node is negative (Wagner, 2000). Immunotherapy has had varied success. Immunotherapy modifies immune function and other biologic responses to cancer. Several forms of immunotherapy (eg, bacillus Calmette-Guérin
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[BCG] vaccine, Corynebacterium parvum, levamisole) offer encouraging results. Some investigational therapies include biologic response modifiers (eg, interferon-alpha, interleukin-2), adaptive immunotherapy (ie, lymphokine-activated killer cells), and monoclonal antibodies directed at melanoma antigens. One of these, proleukin, shows promise in preventing recurrence of melanoma (Demis, 1998). Under investigation is the laboratory assay of tyrosinase, an enzyme believed to be produced only by melanoma cells (Demis, 1998). Several other studies are attempting to develop autologous immunization against specific tumor cells. These studies are still in the early experimental stage but show promise of producing a vaccine against melanoma (Piepkorn, 2000). Current treatments for metastatic melanoma are largely unsuccessful, with cure generally impossible. Further surgical intervention may be performed to debulk the tumor or to remove part of the organ involved (eg, lung, liver, or colon). The rationale for more extensive surgery, however, is for relief of symptoms, not for cure. Chemotherapy for metastatic melanoma may be used; however, only a few agents (eg, dacarbazine, nitrosoureas, cisplatin) have been effective in controlling the disease. When the melanoma is located in an extremity, regional perfusion may be used; the chemotherapeutic agent is perfused directly into the area that contains the melanoma. This approach delivers a high concentration of cytotoxic agents while avoiding systemic, toxic side effects. The limb is perfused for 1 hour with high concentrations of the medication at temperatures of 39°C to 40°C (102.2°F to 104°F) with a perfusion pump. Inducing hyperthermia enhances the effect of the chemotherapy so that a smaller total dose can be used. It is hoped that regional perfusion can control the metastasis, especially if it is used in combination with surgical excision of the primary lesion and with regional lymph node dissection.
NURSING PROCESS: CARE OF THE PATIENT WITH MALIGNANT MELANOMA Assessment Assessment of the patient with malignant melanoma is based on the patient’s history and symptoms. The patient is asked specifically about pruritus, tenderness, and pain, which are not features of a benign nevus. The patient is also questioned about changes in preexisting moles or the development of new, pigmented lesions. People at risk are assessed carefully. A magnifying lens and good lighting are needed for inspecting the skin for irregularity and changes in the mole. Signs that suggest malignant changes are referred to as the ABCDs of moles (Chart 56-8). Common sites of melanomas are the skin of the back, the legs (especially in women), between the toes, and on the feet, face, scalp, fingernails, and backs of hands. In dark-skinned people, melanomas are most likely to occur in less pigmented sites: palms, soles, subungual areas, and mucous membranes. Satellite lesions (ie, those situated near the mole) are inspected.
Diagnosis NURSING DIAGNOSES Based on the nursing assessment data, the patient’s major nursing diagnoses may include the following:
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• ASSESSMENT
a melanoma. Anticipating the need for and administering appropriate analgesic medications are important.
The ABCDs of Moles A for Asymmetry • The lesion does not appear balanced on both sides. If an imaginary line were drawn down the middle, the two halves would not look alike. • The lesion has an irregular surface with uneven elevations (irregular topography) either palpable or visible. A change in the surface may be noted from smooth to scaly. • Some nodular melanomas have a smooth surface. B for Irregular Border • Angular indentations or multiple notches appear in the border • The border is fuzzy or indistinct, as if rubbed with an eraser. C for Variegated Color • Normal moles are usually a uniform light to medium brown. Darker coloration indicates that the melanocytes have penetrated to a deeper layer of the dermis. • Colors that may indicate malignancy if found together within a single lesion are shades of red, white, and blue; shades of blue are ominous. • White areas within a pigmented lesion are suspicious. • Some malignant melanomas, however, are not variegated but are uniformly colored (bluish-black, bluish-gray, bluish-red). D for Diameter • A diameter exceeding 6 mm (about the size of a pencil eraser) is considered more suspicious, although this finding without other signs is not significant. Many benign skin growths are larger than 6 mm, whereas some early melanomas may be smaller.
• Acute pain related to surgical excision and grafting • Anxiety and depression related to possible life-threatening consequences of melanoma and disfigurement
• Deficient knowledge about early signs of melanoma COLLABORATIVE PROBLEMS/ POTENTIAL COMPLICATIONS Based on the assessment data, potential complications include the following:
• Metastasis • Infection of the surgical site Planning and Goals The major goals for the patient may include relief of pain and discomfort, reduced anxiety and depression, knowledge of early signs of melanoma, and absence of complications.
Nursing Interventions RELIEVING PAIN AND DISCOMFORT Surgical removal of melanoma in different locations (eg, head, neck, eye, trunk, abdomen, extremities, central nervous system) presents different challenges, taking into consideration the removal of the primary melanoma, the intervening lymphatic vessels, and the lymph nodes to which metastases may spread. Nursing management of the patient having surgery in these regions is discussed in the appropriate chapters. Nursing intervention after surgery for a malignant melanoma centers on promoting comfort, because wide excision surgery may be necessary. A split-thickness or full-thickness skin graft may be necessary when large defects are created by surgical removal of
REDUCING ANXIETY AND DEPRESSION Psychological support is essential when disfiguring surgery is performed. Support includes allowing patients to express feelings about the seriousness of this cutaneous neoplasm, understanding their anger and depression, and conveying understanding of these feelings. During the diagnostic workup and staging of the depth, type, and extent of the tumor, the nurse answers questions, clarifies information, and helps clarify misconceptions. Learning that they have a melanoma can cause patients considerable fear and anguish. Pointing out patients’ resources, past effective coping mechanisms, and social support systems helps them to cope with the problems associated with diagnosis, treatment, and continuing follow-up. The patient’s family should be included in all discussions to clarify the information presented, ask questions that the patient might be reluctant to ask, and provide emotional support. MONITORING AND MANAGING POTENTIAL COMPLICATIONS Metastasis The prognosis for malignant melanoma is related to metastasis: the deeper and thicker (more than 4 mm) the melanoma, the greater is the likelihood of metastasis. If the melanoma is growing radially (ie, horizontally) and is characterized by peripheral growth with minimal or no dermal invasion, the prognosis is favorable. When the melanoma progresses to the vertical growth phase (ie, dermal invasion), the prognosis is poor. Lesions with ulceration have a poor prognosis. Melanomas of the trunk appear to have a poorer prognosis than those of other sites, perhaps because the network of lymphatics in the trunk permits metastasis to regional lymph nodes. The role of the nurse in caring for the patient with metastatic disease is holistic. The nurse must be knowledgeable about the most effective current therapies and must deliver supportive care, provide and clarify information about the therapy and the rationale for its use, identify potential side effects of therapy and ways to manage them, and instruct the patient and family about the expected outcomes of treatment. The nurse monitors and documents symptoms that may indicate metastasis: lung (eg, difficulty breathing, shortness of breath, increasing cough), bone (eg, pain, decreased mobility and function, pathologic fractures), and liver (eg, change in liver enzyme levels, pain, jaundice). Nursing care is based on the patient’s symptoms. Although the chance of a cure for malignant melanoma that has metastasized is poor, the nurse encourages the patient to have hope in the therapy employed while maintaining a realistic perspective about the disease and ultimate outcome. Moreover, the nurse provides time for the patient to express fears and concerns regarding future activities and relationships, offers information about support groups and contact people, and arranges palliative and hospice care if appropriate (see Chap. 17). PROMOTING HOME AND COMMUNITY-BASED CARE Teaching Patients Self-Care The best hope of controlling the disease lies in educating patients about the early signs of melanoma. Patients at risk are taught to examine their skin and scalp monthly in a systematic manner (Chart 56-9). The nurse also points out that a key factor in the development of malignant melanoma is exposure to sunlight. Because melanoma is thought to be genetically linked, the family and the patient should be taught sun-avoiding measures.
Chart 56-9
• PATIENT EDUCATION How to Examine Your Skin
Step 3 Now position yourself in front of the full-length mirror. Hold up your arms, bent at the elbows, with your palms facing you in the mirror, look at the backs of your forearms and elbows.
Step 1 Make sure the room is well lighted, and that you have nearby a full-length mirror, a hand-held mirror, a hand-held blow dryer, and two chairs or stools. Undress completely.
Step 2 Hold your hands with the palms face up, as shown in the drawing. Look at your palms, fingers, spaces between the fingers, and forearms. Then turn your hands over and examine the backs of your hands, fingers, spaces between the fingers, fingernails and forearms.
Step 5 Still standing in front of the mirror, lift your arms over your head with the palms facing each other. Turn so that your right side is facing the mirror and look at the entire side of your body, your hands and arms, underarms, sides of your trunk, thighs and lower legs. Then turn, and repeat the process with your left side.
Step 4 Again using the full-length mirror, observe the entire front of your body. In turn, look at your face, neck, and arms. Turn your palms to face the mirror and look at your upper arms. Then look at your chest and abdomen; pubic area; thighs and lower legs.
Step 6 With your back toward the fulllength mirror, look at your buttocks and the backs of your thighs and lower legs.
Step 7 Now pick up the hand-held mirror. With your back still to the full-length mirror, examine the back of your neck, and your back and buttocks. Also examine the backs of your arms in this way. Some areas are hard to see, and you may find it helpful to ask your spouse or a friend to assist you.
Step 8 Use the hand-held mirror and the full-length mirror to look at your scalp. Because the scalp is difficult to examine, we suggest you also use a hand-held blow dryer turned to a cool setting, to lift the hair from the scalp. While some people find it easy to hold the mirror in one hand and the dryer in the other, while looking in the full-length mirror, many do not. For the scalp examination in particular, then, you might ask your spouse or a friend to assist you. (continued ) 1693
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Chart 56-9 • PATIENT EDUCATION How to Examine Your Skin (Continued) Step 10 Still sitting, cross one leg over the other. Use the hand-held mirror to examine the top of your foot, the toes, toenails, and spaces between the toes. Then look at the sole or bottom of your foot. Repeat the procedure for the other foot.
Step 9 Sit down and prop up one leg on a chair or stool in front of you as shown. Using the hand-held mirror, examine the inside of the propped-up leg, beginning at the groin area and moving the mirror down the leg to your foot. Repeat the procedure for your other leg. Source: American Cancer Society, Inc., Atlanta, CA; 1-800-ACS-2345.
Evaluation
Other Malignancies of the Skin
EXPECTED PATIENT OUTCOMES Expected patient outcomes may include the following:
KAPOSI’S SARCOMA
1. Experiences relief of pain and discomfort a. States pain is diminishing b. Exhibits healing of surgical scar without heat, redness, or swelling 2. Is less anxious a. Expresses fears and fantasies b. Asks questions about medical condition c. Requests repetition of facts about melanoma d. Identifies support and comfort provided by family member or significant other 3. Demonstrates understanding of the means for detecting and preventing melanoma a. Demonstrates how to conduct self-examination of skin on a monthly basis b. Verbalizes the following danger signals of melanoma: change in size, color, shape, or outline of mole, mole surface, or skin around mole c. Identifies measures to protect self from exposure to sunlight 4. Experiences absence of complications a. Recognizes abnormal signs and symptoms that should be reported to physician b. Complies with recommended follow-up procedures and prevention strategies
METASTATIC SKIN TUMORS The skin is an important, although not a common, site of metastatic cancer. All types of cancer may metastasize to the skin, but carcinoma of the breast is the primary source of cutaneous metastases in women. Other sources include cancer of the large intestine, ovaries, and lungs. In men, the most common primary sites are the lungs, large intestine, oral cavity, kidneys, or stomach. Skin metastases from melanomas are found in both genders. The clinical appearance of metastatic skin lesions is not distinctive, except perhaps in some cases of breast cancer in which diffuse, brawny hardening of the skin of the involved breast is seen. In most instances, metastatic lesions occur as multiple cutaneous or subcutaneous nodules of various sizes that may be skin colored or different shades of red.
First described by Moritz Kaposi in 1872, Kaposi’s sarcoma (KS) has received renewed attention since its association with HIV infection and AIDS. Its occurrence with AIDS involves a more varied and aggressive form of KS than was seen previously. Before the AIDS epidemic, KS was considered a rare malignancy. It was subdivided into three categories: classic KS, African (endemic) KS, and KS associated with immunosuppressant therapy. Classic KS occurs predominantly in men of Mediterranean or Jewish ancestry between the ages of 40 and 70 years. Most patients have nodules or plaques on the lower extremities that rarely metastasize beyond the lower extremities. This KS is chronic, relatively benign, and rarely fatal. African KS affects people predominantly in the eastern half of Africa near the equator. Men are affected more often than women, and children can be affected as well. The disease may resemble classic KS, or it may infiltrate and progress to lymphadenopathic forms. KS associated with immunosuppressive therapy, as in transplant recipients, is characterized by local skin lesions and disseminated visceral and mucocutaneous diseases. The greater the degree of immunosuppression, the higher is the incidence of KS. AIDS-related KS was identified in the early 1980s as distinctly different from previously described types of KS. Typically, it is an aggressive tumor that involves multiple body organs. Its presentation resembles that of KS associated with immunosuppressive therapy. Most patients are between the ages of 20 and 40 years (Odom et al., 2000). More information on this topic can be found in Chapter 52.
BASAL AND SQUAMOUS CELL CARCINOMAS IN THE IMMUNOCOMPROMISED POPULATION The incidence of basal cell carcinoma and squamous cell carcinoma is increased in all immunocompromised individuals, including those infected with HIV. Clinically, the tumors have the same appearance as in non–HIV-infected people; however, in HIV patients, the tumors may grow more rapidly and recur more frequently. These tumors are managed the same as for the general population. Frequent follow-up (every 4 to 6 months) is recommended to monitor for recurrence.
Chapter 56
Dermatologic and Plastic Reconstructive Surgery The word plastic comes from a Greek word meaning to form. Plastic or reconstructive surgery is performed to reconstruct or alter congenital or acquired defects to restore or improve the body’s form and function. Often, the terms plastic and reconstructive are used interchangeably. This type of surgery includes closure of wounds, removal of skin tumors, repair of soft tissue injuries or burns, correction of deformities, and repair of cosmetic defects. Plastic surgery can be used to repair many parts of the body and numerous structures, such as bone, cartilage, fat, fascia, mucous membrane, muscle, nerve, and cutaneous structures. Bone inlays and transplants for deformities and nonunion can be performed, muscle can be transferred, nerves can be reconstructed and spliced, and cartilage can be replaced. As important as any of these measures is the reconstruction of the cutaneous tissues around the neck and the face; this is usually referred to as aesthetic or cosmetic surgery.
WOUND COVERAGE: GRAFTS AND FLAPS Various surgical techniques, including skin grafts and flaps, are used to cover skin wounds.
Skin Grafts Skin grafting is a technique in which a section of skin is detached from its own blood supply and transferred as free tissue to a distant (recipient) site. Skin grafting can be used to repair almost any type of wound and is the most common form of reconstructive surgery.
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Skin grafts are commonly used to repair defects that result from excision of skin tumors, to cover areas denuded of skin (e.g., burns), and to cover wounds in which insufficient skin is available to permit wound closure. They are also used when primary closure of the wound increases the risk for complications or when primary wound closure would interfere with function. Skin grafts may be classified as autografts, allografts, or xenografts. An autograft is tissue obtained from the patient’s own skin. An allograft is tissue obtained from a donor of the same species. These grafts are also called allogeneic or homograft. A xenograft or heterograft is tissue from another species. Grafts are also referred to by their thickness. A skin graft may be a split-thickness (ie, thin, intermediate, or thick) or fullthickness graft, depending on the amount of dermis included in the specimen. A split-thickness graft can be cut at various thicknesses and is commonly used to cover large wounds or defects for which a full-thickness graft or flap is impractical (Fig. 56-8). A full-thickness graft consists of epidermis and the entire dermis without the underlying fat. It is used to cover wounds that are too large to be closed directly. DONOR SITE The donor site is selected with several criteria in mind:
• Achieving the closest possible color match • Matching the texture and hair-bearing qualities • Obtaining the thickest possible skin graft without jeopardizing the healing of the donor site (Fig. 56-9)
• Considering the cosmetic effects of the donor site after healing, so that it is in an inconspicuous location
Epidermis
Dermis
Thin .010" Medium .020"
Splitthickness skin graft
Thick .035" Subcutaneous
Full-thickness skin graft .040"
Muscle
Sweat gland Hair follicle
FIGURE 56-8
Layers of skin appropriate for split-thickness and fullthickness graft.
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The graft, when applied to the recipient site, may be sutured in place. It may be slit and spread apart to cover a greater area. The process of revascularization (ie, establishing the blood supply) and reattachment of a skin graft to a recipient bed is referred to as a “take.” After a skin graft is put in place, it may be left exposed (in areas that are impossible to immobilize) or covered with a light dressing or a pressure dressing, depending on the area.
Nursing Interventions
Split-thickness grafts Full-thickness grafts Fat-dermal grafts
FIGURE 56-9
Common donor skin graft sites. Blue skin areas are appropriate for full-thickness grafts; green areas are used for split-thickness grafts; rose sites are used for fat-dermal grafts.
DONOR SITE CARE Detailed attention to the donor site is just as important as the care of the recipient area. The donor site heals by re-epithelization of the raw, exposed dermis. Usually, a single layer of nonadherent, finemesh gauze is placed directly over the donor site. Absorbent gauze dressings are then placed on top to absorb blood or serum from the wound. A membrane dressing (eg, Op-Site) may be used and provides certain advantages. It is transparent and allows the wound to be observed without disturbing the dressing, and it permits the patient to shower without fear of saturating the dressing with water. After healing, the patient is instructed to keep the donor site soft and pliable with cream (eg, lanolin, olive oil). Extremes in temperature, external trauma, and sunlight are to be avoided for donor sites and grafted areas because these areas are sensitive, especially to thermal injuries. GRAFT APPLICATION A graft is obtained by a variety of instruments: razor blades, skingrafting knives, electric- or air-powered dermatomes, or drum dermatomes. The skin graft is taken from the donor or host site and applied to the desired site, called the recipient site or graft bed. For a graft to survive and be effective, certain conditions must be met:
• The recipient site must have an adequate blood supply so that normal physiologic function can resume.
• The graft must be in close contact with its bed to avoid accumulation of blood or fluid.
• The graft must be fixed firmly (immobilized) so that it remains in place on the recipient site.
• The area must be free of infection.
The nurse instructs the patient to keep the affected part immobilized as much as possible. For a facial graft, strenuous activity must be avoided. A graft on the hand or arm may be immobilized with a splint. When a graft is placed on a lower extremity, the part is kept elevated because the new capillary connections are fragile and excess venous pressure may cause rupture. When ambulation is permitted, the patient wears an elastic stocking to counterbalance venous pressure. The nurse instructs the patient, family member, or other caregiver to inspect the dressing daily. Unusual drainage or an inflammatory reaction around the wound margin suggests infection and should be reported to the physician. Any fluid, purulent drainage, blood, or serum that has collected is gently evacuated by the surgeon, because accumulation of this material would cause the graft to separate from its bed. When the graft appears pink, it is vascularized. After 2 to 3 weeks, mineral oil or a lanolin cream is massaged into the wound to moisten the graft. Because there may be loss of feeling or sensation in the grafted area for a prolonged period, the application of heating pads and exposure to sun are avoided to prevent burns and further skin trauma.
Flaps Another form of wound coverage is provided by flaps. A flap is a segment of tissue that remains attached at one end (ie, a base or pedicle) while the other end is moved to a recipient area. Its survival depends on functioning arterial and venous blood supplies and lymphatic drainage in its pedicle or base. A flap differs from a graft in that a portion of the tissue is attached to its original site and retains its blood supply. An exception is the free flap, which is described later. Flaps may consist of skin, mucosa, muscle, adipose tissue, omentum, and bone. They are used for wound coverage and provide bulk, especially when bone, tendon, blood vessels, or nerve tissue is exposed. Flaps are used to repair defects caused by congenital deformity, trauma, or tumor ablation (ie, removal, usually by excision) in an adjacent part of the body. Flaps offer an aesthetic solution because a flap retains the color and texture of the donor area, is more likely to survive than a graft, and can be used to cover nerves, tendons, and blood vessels. However, several surgical procedures are usually required to advance a flap. The major complication is necrosis of the pedicle or base as a result of failure of the blood supply.
Free Flaps A striking advance in reconstructive surgery is the use of free flaps or free-tissue transfer achieved by microvascular techniques. A free flap is completely severed from the body and transferred to another site. A free flap receives early vascular supply from microvascular anastomosis (ie, attachment) with vessels at the recipient site. The procedure usually is completed in one step, eliminating
Chapter 56 the need for a series of surgical procedures to move the flap. Microvascular surgery allows surgeons to use a variety of donor sites for tissue reconstruction.
CHEMICAL FACE PEELING Chemical face peeling, a technique that involves applying a chemical mixture to the face for superficial destruction of the epidermis and the upper layers of the dermis, treats fine wrinkles, keratoses, and pigment problems. It is especially useful for wrinkles at the upper and lower lip, forehead, and periorbital areas. Pretreatment may consist of cleansing the face and hair for several days before the procedure with a hexachlorophene detergent. Pretreatment medication (ie, analgesic and tranquilizer for moderate sedation) may be prescribed to alleviate apprehension and control pain. This permits the patient to be sedated but conscious during the procedure, although some patients request general anesthesia. The type of chemical used depends on the planned depth of the peel. A phenol-based chemical in an oil–water emulsion is commonly used because it produces a controlled, predictable chemical burn. The chemical is applied systematically to the face with cotton-tipped applicators. The conscious patient feels a burning sensation at this time. A mask of waterproof adhesive may then be applied directly to the skin and molded closely to the contours of the face, thereby acting as an occlusive dressing that increases the chemical penetration and action. Some surgeons believe that equally good results can be obtained with occlusive tape. After the tape mask is applied, the burning sensation continues, and the tape mask remains in place for 12 to 24 hours. Frequent small doses of analgesics and tranquilizers are prescribed to keep the patient comfortable.
Complications Complications may arise when control of the chemically induced burn cannot be sustained. Complications include pigment changes, infection, milia (ie, small inclusion cysts that disappear after several months), scarring, atrophy, sensitivity changes, and long-term (4 to 5 months) erythema or pruritus.
Management Because chemical face peeling is performed in the physician’s office or in an outpatient surgical department, most care takes place in the home. After 6 to 8 hours, the face becomes edematous and the eyelids usually swell shut. The patient should be reassured that this reaction is expected and normal. The patient is cautioned to move the mouth as little as possible so that the tape continues to adhere to the skin. The head of the bed is elevated, and liquids are administered through a straw. Most of the burning sensation and discomfort subside after the first 12 to 24 hours. By the second day, the patient may feel moisture under the dressings as serous exudate seeps from the chemically exfoliated skin. Dressings are usually removed 24 to 48 hours after treatment, exposing skin resembling a second-degree burn. The patient may be alarmed by the appearance of the skin and should be reassured. After the tape mask is removed, some surgeons dust the treated skin surface with thymol-iodine powder for its drying and bacteriostatic effects. Application of triple-antibiotic ointment may be substituted in some cases. The skin surface is left uncovered to dry. The patient may be permitted to wash the face with lukewarm water or advised to shower several times daily to help remove
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any remaining facial crusting. An ointment is prescribed to cover the face and soften and loosen the crust between washings. The nurse reinforces the physician’s explanation that the redness of the skin will gradually subside over the next 4 to 12 weeks. Although a line between treated and untreated skin may be seen, makeup is usually permitted after the first few weeks. The patient is cautioned to avoid exposure to direct or reflected sunlight, because the treatment reduces the natural protection of the skin from sun. The skin will probably never tan evenly again. Blotchy pigmentation can occur with exposure to the sun.
DERMABRASION Dermabrasion is a form of skin abrasion used to correct acne scarring, aging, and sun-damaged skin. A special instrument (ie, motordriven wire brush, diamond-impregnated disk, or serrated wheel) is used in the procedure. The epidermis and some superficial dermis are removed, while enough of the dermis is preserved to allow re-epithelization of the treated areas. Results are best in the face because it is rich in intradermal epithelial elements.
Preparation and Procedure The primary reason for undergoing dermabrasion is to improve appearance. The surgeon explains to the patient what can be expected from dermabrasion. The patient should also be informed about the nature of the postoperative dressing, what discomfort may be experienced, and how long it will be before the tissues look normal. Dermabrasion may be performed in the physician’s office, the operating room, or an outpatient setting. It is performed under local or general anesthesia. During the procedure, some surgeons use refrigerant anesthetics to turn the skin into a numb, solid mass of rigid tissue and to provide a momentarily bloodless surgical field. During and after planning, the area is irrigated with copious amounts of saline solution to remove debris and allow the surgeon to see the area. A dressing impregnated with ointment is usually applied to the abraded surface.
Management The nurse instructs the patient about postoperative effects. Edema occurs during the first 48 hours and may cause the eyelids to close. The head of the bed is elevated to hasten fluid drainage. Erythema occurs and can last for weeks or months. After 24 hours, the dressing may be removed if the physician approves. When the serum oozing from the skin begins to gel, the patient applies the prescribed ointment to the face several times each day to prevent hard crusting and to keep the abraded areas soft and flexible. With the physician’s approval, clear-water cleansing or soaking of the face is started to remove crusts from the healing skin. The patient is advised to avoid extreme cold and heat and excessive straining or lifting, which may bruise delicate new capillaries. Direct or reflected sunlight should be avoided for 3 to 6 months and a sunscreen used.
FACIAL RECONSTRUCTIVE SURGERY Reconstructive procedures on the face are individualized to the patient’s needs and desired outcomes. They are performed to repair deformities or restore normal function as much as possible. They may vary from closure of small defects to complicated procedures involving implantation of prosthetic devices to conceal a
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large defect or reconstruct a lost part of the face (eg, nose, ear, jaw). Each surgical procedure is customized and involves a variety of incisions, flaps, and grafts. In correcting a primary defect, the surgeon may have to create a secondary defect. Although the procedure may restore some function, such as eating or talking, the cosmetic or aesthetic results may be limited. The original appearance of a patient who has severe damage to soft tissue and bone structure can seldom be restored. Multiple surgical procedures may be required. The process of facial reconstruction is usually slow and tedious.
COLLABORATIVE PROBLEMS/ POTENTIAL COMPLICATIONS Based on the assessment data, potential complications that may develop include.
NURSING PROCESS: CARE OF THE PATIENT WITH FACIAL RECONSTRUCTION
The major goals for the patient may include a patent airway and adequate pulmonary function, increased comfort, adequate nutritional status, an effective communication method, positive selfconcept, effective family coping, and absence of infection.
Assessment The face is a part of the body that every person desires to keep at its best or improve, because most human interactions involve the face. When the face loses its appearance and function by injury or disease, significant emotional reactions often occur. Changes in appearance frequently cause anxiety and depression. Patients with facial changes frequently mourn for the lost part, suffer a loss of self-esteem because of reactions or rejection by others, and withdraw and isolate themselves. Health care personnel can acknowledge that anxiety and depression are appropriate for what the patient is experiencing. The nurse assesses the patient’s emotional responses and identifies strengths as well as usual coping mechanisms to determine how the patient will handle the surgical procedure. Any area in which the patient and family need extra support is identified. The preoperative assessment determines the extent of disfigurement and improvement that can be anticipated, as well as the patient’s understanding and acceptance of these limitations. The nurse is in a better position to reinforce facts and clarify misconceptions after the surgeon has fully informed the patient about the procedure, the functional defects that may result, the possible need for a tracheostomy or other prosthesis, and the probability of additional surgery. The nurse instructs the patient about various postoperative measures: intravenous therapy, the use of a nasogastric tube to allow gastric decompression and prevent vomiting, and the frequent and lengthy periods that may be required to care for wounds, flaps, and skin grafts and to change dressings. Extra time is needed when presenting this information to anxious patients because they may not hear, concentrate, or comprehend what is being said.
Diagnosis NURSING DIAGNOSES Based on the nursing assessment data, the patient’s major postoperative nursing diagnoses may include the following:
• Ineffective airway clearance related to tracheobronchial secretions
• Acute pain related to facial edema and effects of the procedure
• Imbalanced nutrition: less than body requirements related • •
to altered physiology of oral cavity, drooling, impaired chewing and swallowing, or excision affecting the tongue Impaired verbal communication related to trauma or surgery producing anatomic and physiologic abnormalities of speech Disturbed body image related to disfigurement
• Interrupted family processes related to grief reaction and disruption of family life
• Infection Planning and Goals
Nursing Interventions MAINTAINING AIRWAY AND PULMONARY FUNCTION The immediate concern after facial reconstruction is maintenance of an adequate airway. If the patient has regained consciousness, mental confusion with combative, anxious behavior is a sign of hypoxia (ie, reduced oxygen supply to tissues). Sedatives or opioids are not prescribed in this situation because they may impair oxygenation. If the patient shows signs of restlessness, the airway is carefully inspected to detect laryngeal edema or accumulation of tracheobronchial mucus. Secretions are suctioned as necessary until the patient can manage the secretions without help. If the patient has a tracheostomy, suctioning is performed with sterile technique to prevent infection and cross-contamination. Chapter 25 provides information on care of the patient with a tracheostomy. RELIEVING PAIN AND ACHIEVING COMFORT Facial edema is an uncomfortable but natural consequence of facial reconstructive surgery. The patient’s head and upper torso are kept slightly elevated (if the blood pressure is stable) to help reduce facial edema. Catheters attached to closed drainage may be in place to keep the tissue in close apposition and to remove serous discharge. If extensive reconstruction has been performed, the patient’s head should be properly aligned and supported so that minimal stress is placed on the suture line. Analgesics are prescribed to relieve pain. If bone grafts have been used for reconstruction, there is usually considerable pain in the donor area. If the patient has head and neck cancer and increasing levels of pain, comprehensive nursing management is required (see Chap. 13). MAINTAINING ADEQUATE NUTRITION Fluids may be offered to the patient after oral and pharyngeal edema diminish, the incisional areas and flaps heal, and the patient can swallow saliva. Gradually, soft foods are added as tolerated. If the patient cannot meet nutritional needs by the oral route, parenteral nutrition (ie, infusion of nutrients, water, and vitamins into the stomach or proximal small intestine through a tube) is initiated. The formula strength and feeding rate are gradually increased until the desired daily caloric level is attained. Chapter 36 provides information about nursing management of the patient requiring enteral feedings. Patients who have had radical surgery for large, encroaching neoplasms may have difficulty resuming eating. Positive nutrition is reflected in weight gain, and nutritional status is monitored by measuring body weight daily and assessing serum protein and electrolyte levels periodically.
Chapter 56 ENHANCING COMMUNICATION Communication problems may range from minimal difficulty to the loss of oral speech. Some tumors and injuries require extensive surgery involving the larynx, tongue, and mandible. Paper, pen or pencil, and a firm writing surface should be provided. If the patient cannot write, a pictograph board may be used. Referral to a speech therapist may be necessary for the patient who has undergone structural changes. The family may become frustrated by the patient’s inability to communicate. The patient soon senses this, and both parties may withdraw. Allowing the family to vent their feelings and fears (away from the patient) is important. IMPROVING SELF-CONCEPT Success in rehabilitating the patient undergoing reconstructive surgery depends on the relationships among the patient and the nurse, the physician, and other health care personnel. Mutual trust, respect, and clear lines of communication are essential. Unhurried care provides emotional reassurance and support. The kinds of dressings worn, the unusual positions to be maintained, and the temporary incapacity experienced can upset the most stable person. Reinforcement of the patient’s successful coping strategies improves self-esteem. If prosthetic devices are used, the patient is taught how to use and care for them to gain a sense of greater independence. Once involved in self-care activities, the patient may feel some control over what was previously an overwhelming situation. Patients with severe disfigurement are encouraged to socialize to experience the reactions of others in a more protected environment. Gradually, they can widen their sphere of contact. Every effort is made to cover or mask defects. Patients may require support by members of the mental health team to accept their changed appearance. PROMOTING FAMILY COPING The family is informed about the patient’s appearance after surgery, the supportive equipment, and the ways that the equipment aids recovery. It is helpful to join the family for a few minutes during their first postoperative visit to help them cope with the changes they will see. A major role of the nurse is to support the family in their decision to participate (or not to participate) in the patient’s treatment. Nursing interventions also include helping the family members communicate by suggesting ways to reduce anxiety and stress and to promote problem solving and decision making. These activities encourage family members and promote growth. MONITORING AND MANAGING POTENTIAL COMPLICATIONS Infection Secondary infection is a primary concern after reconstructive surgery. The source of infection depends on the location and extent of the procedure, the suture line, and the pedicle flap. The mouth is inspected to determine the location of sutures (when present) so that they are not accidentally disturbed during the cleaning process. The mouth is cleaned according to protocol several times daily. Loose blood clots may be removed with gentle swabbing. The patient is advised not to loosen clots with the tongue because this may cause fresh bleeding. The patient is instructed not to use fingers to clean or remove blood clots because this may introduce organisms that cause infection. The suture line remains under stress for several days after surgery because of edema, increased drainage, and hematoma formation. The nurse assesses the suture line carefully for signs of
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increased tension and infection (ie, elevated temperature, increasing edema, redness, bleeding, and increased pain) with each dressing change. Dressings may need to be changed many times each day until the drainage begins to decrease. Drainage and edema are expected after reconstructive surgery; however, both should decrease, and the process is hastened by using properly placed, functioning suction devices and elevating the head of the bed about 45 degrees. The nurse inspects the suction devices, empties them promptly, and documents the amount and consistency of drainage, as well as any unusual odor. When drainage is not removed or if saturated dressings are left unchanged for long periods, infection is likely to occur. Strict asepsis must be maintained in wound care. A pedicle flap used in reconstruction may become a source of infection if its circulation becomes compromised. Poor circulation may result from a hematoma forming beneath the flap and causing increased pressure on the underlying vasculature. The nurse inspects the flap for changes in color and temperature indicative of poor circulation. Signs of necrosis, increased drainage, or an odor may be a warning of an infection and should be reported promptly. Reinforcing preoperative teaching about wound healing, the need for strict sterile technique, good personal hygiene, and the need to restrict movement and stress on the operative site is an important part of the nurse’s role in postoperative care and in the prevention of secondary infection.
Evaluation EXPECTED PATIENT OUTCOMES Expected patient outcomes may include the following: 1. Maintains patent airway a. Demonstrates respiratory rate within normal limits b. Exhibits normal breath sounds c. Demonstrates no signs of choking or aspiration 2. Achieves increasing comfort a. Reports decreasing pain b. Follows instructions on proper positioning c. Avoids movements that stress the operative site 3. Attains adequate nutrition a. Consumes adequate amounts of food and fluids b. Maintains weight within normal range or progressively regains weight lost in the early postoperative period c. Maintains serum protein and electrolyte levels within normal range 4. Communicates effectively a. Uses appropriate aids to enhance communication b. Interacts with health care team members, family, and other support people using new communication strategies 5. Develops positive self-image a. Expresses positive feelings about surgical changes b. Demonstrates increasing independence in self-care activities c. Uses prosthetic devices independently (when appropriate) d. Verbalizes plans for resuming usual activities (eg, work, recreation) 6. Family members cope with situation a. Demonstrate decreasing anxiety and conflict b. Verbalize what to expect 7. Absence of complications a. Demonstrates vital signs within normal limits b. Undergoes normal wound healing without signs of infection or sepsis
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c. Lists signs of infection that should be reported d. Understands the need for asepsis (ie, sterile procedures) and good personal hygiene
FACE LIFT Rhytidectomy (ie, face lift) is a surgical procedure that removes soft tissue folds and minimizes cutaneous wrinkles on the face. It is performed to create a more youthful appearance. Psychological preparation requires that the patient recognize the limitations of surgery and the fact that miraculous rejuvenation will not occur. The patient is informed that the face may appear bruised and swollen after the dressings are removed and that several weeks may pass before the edema subsides. The procedure is performed under local or general anesthesia, often in the outpatient setting. The incisions are concealed in natural skin folds and creases and areas hidden by hair. The loose skin, separated from underlying muscle, is pulled upward and backward. Excess skin that overlaps the incision line is removed. Liposuction-assisted rhytidectomy is being performed more frequently. In this procedure, fat is suctioned from the body through a cannula inserted through a small incision.
Management The nurse encourages the patient to rest quietly for the first 2 postoperative days until the dressings are removed. The head of the bed is elevated, and neck flexion is discouraged to avoid compromising the circulation and the suture line. The patient may feel some tightness of the face and neck from pressure created by the newly tightened muscles, fascia, and skin. Analgesics may be prescribed to relieve discomfort. A liquid diet may be given by means of straws, and a soft diet is permitted if chewing is not too uncomfortable. When the dressings are removed, the skin is gently cleaned of crusting and oozing and coated with the prescribed topical ointment. Any hair matted with drainage may be combed with warm water and a wide-toothed comb. The patient is advised not to lift or bend for 7 to 10 days because this activity may increase edema and provoke bleeding. Activities are gradually resumed. When all sutures are removed, the hair may be shampooed and blown dry with warm, not hot, air to avoid burning the ears, which may be numb for a while. The patient needs to know that a face lift will not stop the aging process and that, with time, the tissues will resume the downward drift. Some patients have two or more face lifts. Sudden pain indicates that blood is accumulating underneath the skin flaps; it should be reported to the surgeon immediately. Complications include sloughing of the skin, deformities of the face and neck, and partial facial paralysis. Cigarette smoking has been implicated as a cause of skin slough in some patients.
Laser Treatment of Cutaneous Lesions Lasers are devices that amplify or generate highly specialized light energy. They can mobilize immense heat and power when focused at close range and are valuable tools in surgical procedures. The argon laser, carbon dioxide (CO2) laser, and tunable pulsedye laser are used in dermatologic surgery. Each type of laser emits its own wavelength within the color spectrum.
ARGON LASER The argon laser produces a visible blue-green light that is absorbed by vascular tissue and is therefore useful in treating vascular lesions: port-wine stains, telangiectases, vascular tumors, and pigmented lesions. The argon beam can penetrate approximately 1 mm of skin and reach the pigmented layer, causing protein coagulation in this area. An immediate effect is that tiny blood vessels under the skin coagulate, causing the area to turn a much lighter color. A crust forms within a few days. During the procedure, the patient may require local anesthesia (lidocaine) but only if the lesion, such as a port-wine stain, is wider than 0.5 cm. Laser beams, regardless of type, are reflected and scattered in all directions during the treatment. Laser radiation is hazardous to the eye, and the eyes of the patient and all personnel involved in the surgical procedure and those who are within the immediate surgical environment must be protected with orange, argon light–absorbing safety goggles.
Management Cold compresses are usually applied over the treatment area for approximately 6 hours to minimize edema, exudate, and loss of capillary permeability. The nurse advises the patient that swelling will subside in 1 to 2 days and will be followed by a crust that will last 7 to 10 days. The nurse instructs the patient to avoid picking at the crust, to apply an antibacterial ointment sparingly until the crust separates, to avoid applying makeup until the wound heals, and to avoid exposure to the sun. Sunscreen is to be used when exposure is unavoidable.
CARBON DIOXIDE LASER The CO2 laser emits invisible light in the infrared spectrum that is absorbed at the skin surface because of the high water content of the skin and the long wavelength of the CO2 light. As the laser beam strikes tissue, it is absorbed by the intracellular and extracellular water, which vaporizes, destroying the tissue. The CO2 laser is a precise surgical instrument that vaporizes and excises tissue with minimal damage. Because the beam can seal blood and lymphatic vessels, it creates a dry surgical field that makes many procedures easier and quicker. It is therefore safe to use on patients with bleeding disorders or those receiving anticoagulant therapy. It is useful for removing epidermal nevi, tattoos, certain warts, skin cancer, ingrown toenails, and keloids. Incisions made with the laser beam heal and scar much like those made by a scalpel. In addition to wearing safety goggles, the patient and personnel wear laser-grade surgical masks to avoid inhaling the byproduct smoke, referred to as a plume.
Management Immediately after undergoing CO2 laser surgery, the treated area turns a charcoal color. The wound is covered with antibacterial ointment and a nonadhesive dressing. The patient is instructed to keep the wound dry except for gentle cleansing with mild soap several times each day. After the skin is cleaned, a prescribed ointment and light dressing are applied. Because nerve endings and lymphatic vessels are sealed by the laser, less edema and pain follow the laser procedure than follow conventional surgery. A mild analgesic is sufficient to maintain
Chapter 56 patient comfort. Wound healing occurs by secondary intention, with granulation tissue appearing within a week; complete healing occurs in several weeks. Sun exposure to the area should be avoided for approximately 6 months. Application of a sunscreen with an SPF value of at least 15 is recommended. People at high risk for skin cancer from sun exposure are advised to use a sunscreen with an SPF greater than 15 to block ultraviolet-B and ultraviolet-A light.
PULSE-DYE LASER The tunable pulse-dye laser with various wavelengths is the latest laser available for dermatologic surgery. It is especially useful in treating cutaneous vascular lesions such as port-wine stains and telangiectasia. Eye protection used for the argon and CO2 lasers is insufficient when the pulse-dye laser is in use. Special eyeglasses, such as those made of didymium glass, are required for the patient and all personnel. The procedure is generally painless. For procedures requiring anesthesia, lidocaine without epinephrine is sufficient because local vasoconstriction (which epinephrine induces) is unnecessary.
Management The patient should be informed that there may be stinging in the treated area for several hours. Applying ice to the area and a light antibacterial ointment followed by a nonstick dressing (eg, Telfa) usually eases discomfort.
!
NURSING ALERT Telfa pads contain latex and should not be used on patients who are latex sensitive. Other dressings such as petrolatum-impregnated gauze should be used to prevent the dressing from adhering to the wound.
If crusting occurs, the patient is advised to wash the area gently with soap and water and reapply the antibacterial cream twice daily until the crust disappears. The nurse also advises the patient to avoid wearing makeup until all crust is removed. Sun exposure should be avoided as well; sunscreens with an SPF value of 15 or greater should be used for 3 to 4 months after the treatment. Complete removal of the lesion at one session, especially a portwine stain, is rare. The patient should be informed that several treatments may be necessary.
?
Critical Thinking Exercises
1.
A patient is admitted with generalized psoriasis in an acute flare. About 70% of his skin is involved. What type of treatment will you be expected to administer? What nursing interventions would you anticipate in caring for this man? Explain the physiologic basis for these interventions.
2.
You are caring for an elderly man who has had surgery. He is a regular resident of a long-term care facility. When giving him a bath, you find two ulcerations on his buttocks. What are some of the considerations in taking care of this man? What will help prevent further breakdown of the skin?
Management of Patients With Dermatologic Problems
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Which dressings may be appropriate for his wounds? What other hospital resources can you consult in making a care plan for this patient?
3.
A middle-aged woman is admitted to same-day surgery for a wide excision of a melanoma on her back. She is very anxious about the cause of this cancer and about her prognosis. What issues would you address in helping her diminish her anxiety? What should she be told about sun exposure? What should she tell her children about their risk for melanoma?
REFERENCES AND SELECTED READINGS American Cancer Society. (2002). Cancer facts and figures. Atlanta, GA: (Author) Barton, S. (Ed.). (2001) Clinical evidence (5th ed.). London: BJM Publishing. Champion, R. H., Burton, J. L., Burns, D. A., & Breathnach, S. M. (1998). Rook/Wilkinson/Ebling textbook of dermatology (6th ed.). Boston: Blackwell Science. Demis, D. J. (Ed.). (1998). Clinical dermatology. Philadelphia: LippincottRaven. Fitzpatrick, T. B., et al. (1997). Color atlas & synopsis of clinical dermatology (3rd ed.). New York: McGraw-Hill. Freedberg, I. M., Eisen, A. Z., Austen, K. F., Goldsmith, S. I., Katz, S., & Fitzpatrick, T. B. (1999). Fitzpatrick’s dermatology in general medicine (5th ed.). New York: McGraw-Hill. Hall, J. (Ed.). (2000). Sauer’s manual of skin diseases (8th ed.). Philadelphia: Lippincott Williams & Wilkins. Krastner, D. L., Rodeheaver, G. O., & Sibbald, R. G. (2002). Chronic wound care: A clinical source book for healthcare professionals (3rd ed.). Wayne, PA: HMP Communications. Murphy, J. L. (Ed.) (2002). Nurse practitioners’ prescribing reference. New York: Prescribing Reference. Odom, R. B., James, W. D., & Berger, T. G. (Eds.). (2000). Andrews’ diseases of the skin (9th ed.). Philadelphia: W. B. Saunders.
Journals Aly, R., Forney, R., & Bayles, C. (2001). Treatments for common superficial fungal infections. Dermatology Nursing, 2, 91–101. Bryant, R. A., & Rolstad, B. S. (2001). Examining threats to skin integrity. Ostomy Wound Management, 47(6), 18–27. Choucair, M. M., & Fivenson, D. P. (2001). Leg ulcer diagnosis and management. Dermatologic Clinics, 19(4), 52–56. Crissey, J. T. (1998). Common dermatophyte infections: A simple diagnostic test and current management. Postgraduate Medicine, 103(2), 191–205. Crutchfield, C. E. (1998). The causes and treatment of pseudofolliculitis barbae. Cutis, 61(6), 351–356. Fleischer, A. B., Feldman, S. R., & Rapp, S. R. (2000). The magnitude of skin disease in the United States. Dermatologic Clinics, 18(2), 76–81. Goolsby, M. J. (1998). The elusive itch: Assessment, diagnosis, and management of pruritus. Advance for Nurse Practitioners, 6, 61–64. Gritter, M. (1998). The latex threat. American Journal of Nursing, 98(9), 26–33. Halder, R. M. (2000). New and emerging therapies for vitiligo. Dermatologic Clinics, 18(1), 79–89, ix. Harrigan, E. (1999). Atopic dermatitis. Immunology and Allergy Clinics of North America, 19(2), 383–396. Hilton, D. C., Williams, L. C., & Nesbitt, L. T. (2000). Systemic glucocorticosteroid therapy in dermatology. Dermatology Nursing, 12(4), 258–263. Joe, E. K., Li, V. W., Magro, C. M., Arndt, K. A., & Bowers, K. E. (1999). Diagnostic clues to dermatitis artefacta. Cutis, 63(4), 209–214. Koo, J. Y., Lowe, N. J., Lew-Kaya, D. A., Vasilopoulos, A. L., Lue, J. C., Sefton, J., & Gibson, J. R. (2000). Tazarotene plus UV-B photo-
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therapy in the treatment of psoriasis. Journal of the American Academy of Dermatology, 43(5 Pt. 1), 821–828. Kunimoto, B. (2001). Management and prevention of venous leg ulcers: A literature-guided approach. Ostomy Wound Management, 47(2), 36– 46, 48–50. Landi, G., & Landi, C. (2001). The sentinel node biopsy in melanoma patients. Dermatology Nursing, 13(6), 429–434. Lebwohl, M. (2000). Advances in psoriasis therapy. Dermatologic Clinics, 18(1), 62–66. Lee, S. W., Li, H., Strong, T. V., et al. (2000). Development of a polynucleotide vaccine from melanoma antigen recognized by T cells-1 and recombinant protein from melanoma antigen recognized by T cells-1 for melanoma vaccine clinical trials. Journal of Immunotherapy, 23, 379–386. Levin, N., & Greer, K. E. (2000). Cutaneous manifestations of endocrine disorders. Dermatology Nursing, 13(3), 185–195. Leung, D. Y. (2000). Atopic dermatitis: New insights and opportunities for therapeutic intervention. Journal of Allergy and Clinical Immunology, 105, 860–876. Lim, H. W., et al. (2001). American Academy of Dermatology Consensus Conference on UVA Protection of Sunscreens: Summary and recommendations. Journal of American Academy of Dermatology, 44(3), 505–508. McCowan, C. B. (1998). Systemic lupus erythematosus. Journal of the American Academy of Nurse Practitioners, 10(5), 225–231. Mercurio, M. G. (1998). Managing the patient with hirsutism. Hospital Medicine, 34(9), 45–51. Mutasim, D. F. (2002). Bullous diseases in the elderly. Clinics in Geriatric Medicine, 18(1), 43–58. Nall, L., Gulliver, W., Charmley, P., & Farber, E. M. (1999). Search for the psoriasis susceptibility gene: The Newfoundland Study. Cutis, 64(5), 323–330. Nilsson, T. N., Klang, B., & Berg, M. (1999). Patient education for adults with chronic eczema. Dermatology Nursing, 11(2), 117–122. Noble, S. L., Forbes, R. C., & Stamm, P. L. (1998). Diagnosis and management of common tinea infections. American Family Physician, 58(1), 163–178. Paquette, D., & Falanga, V. (2002). Geriatric dermatology. Part II. Leg ulcers. Clinics in Geriatric Medicine, 18(1), 154–162. Piepkorn, M. (2000). Melanoma genetics: An update with focus on the CDKN2A(p16)/ARF tumor suppressors. Journal of the American Academy of Dermatology, 43(2), 705–722. Pullen, R. L. (2001). Managing subacute cutaneous lupus erythematosus. Dermatology Nursing, 13(6), 419–426. Raza, A., Rutledge, F., & Bayles, C. (2001). Treatments for common superficial fungal infections. Dermatology Nursing, 2, 91–100. Robinson, J. K. (2000). Early detection and treatment of melanoma: Update 2000. Dermatology Nursing, 12(6), 397-402. Rodgers, P. (2001). Treating onychomycosis. American Family Physician, 63(4), 663–672. Romero, P., & Alster T. (2001). Skin rejuvenation with cool touch 1320 nm Nd:YAG laser: The nurse’s role. Dermatology Nursing, 13(2), 122–127. Rousseau, R. F., Hirschmann-Jax, C., Takahashi, S., & Brenner, M. K. (2001). Cancer vaccines. Hematology/Oncology Clinics of North America, 15(4), 741–773. Rutter, A., & Luger, T. A. (2001). Clinical review: High dose intravenous immunoglobulins. Journal of the American Academy of Dermatology, 44(6), 213–219.
Shaw, J. C. (2001). Hormonal therapy in dermatology. Dermatologic Clinics, 19(1), 169–178. Shelk, J., & Morgan, P. (2000). Narrow band UVB: A practical approach. Dermatology Nursing, 12(6), 407–411. Shindl, A., & Neumann, R. (1999). Low-intensity laser therapy is an effective treatment for recurrent herpes simplex infections. Journal of Investigative Dermatology, 113(2), 221–223. Talarico, L. D. (1998). Aging skin: Best approaches to common problems. Patient Care Nurse Practitioner, 1(5), 28–40. Valencia, I. C., Falabella, A., Dirsner, R. S., & Eaglestein, W. H. (2001). Chronic venous insufficiency and venous leg ulcers. Journal of the American Academy of Dermatology, 44(3), 401–421. Wachsmuth, R. C. (1998). The atypical mole syndrome and predisposition to melanoma. New England Journal of Medicine, 339(5), 348–349. Wagner, J. D. (2000). Sentinel lymph node biopsy for melanoma: Experience with 234 consecutive procedures. Plastic Reconstruction Surgery, 105(6), 1956–1966. Williams, L. C. (2001). Update on systemic glucocorticosteroids in dermatology. Dermatologic Clinics, 19(1), 63–77. Wolkenstein, P. (2000). Toxic epidermal necrolysis. Dermatologic Clinics, 18(3), 485–495. Wolkenstein, P. E., Roujeau, J. C., & Revuz, J. (1998). Druginduced toxic epidermal necrolysis. Clinical Dermatology, 16(3), 399–408.
RESOURCES AND WEBSITES Dermatology online atlas, a cooperation between the Department of Clinical Social Medicine (University of Heidelberg) and the Department of Dermatology (University of Erlangen); http://www.dermis.net. Foundation for Ichthyosis & Related Skin Types, 650 N. Cannon Avenue, Suite 17, Lansdale, PA 19446; 215-631-1411; http://www. scalyskin.org. Lupus Foundation, 1300 Piccard Dr., Rockville, MD 29850-4303; 301-670-9292; http://www.lupus.org. Medscape online sources for medical information; http://www.medscape. com. National Alopecia Areata Foundation (NAAF) P.O. Box 150760, San Rafael, CA 94915-0760; 415-472-3780; http://www.alopeciaareata. com. National Eczema Association for Science and Education, 1220 S. W. Morrison, Suite 433, Portland, OR 97205; 451-499-3474; http:// www.eczema-assn.org. National Organization for Albinism and Hypopigmentation, PO Box 959, East Hampstead, NH 03826-0959; 1-800-473-2310; http://www.albinism.org. National Pressure Ulcer Advisory Panel, 11250 Roger Bacon Dr., Suite 8, Reston, VA 20190-5202; 703-464-4849; http://www.npuap.org. National Psoriasis Foundation (USA), 6600 S.W. 92nd Ave., Suite 300, Portland, OR 97223-7195; 503-244-7404; http://www.psoriasis.org. National Rosacea Society, 800 South Northwest Highway, Suite 200, Barrington, IL 60010;1-888-NO-BLUSH; http://www.rosacea.org. National Vitiligo Foundation, 611 South Fleishel Ave., Tyler, TX 75701; 903-531-0074; http://www.nvfi.org. New Zealand Dermatology Society; http://www.dermnetnz.org. Skin Cancer Foundation, 575 Park Ave. S., New York, NY 10016; 1-800SKIN-490; http://www.skincancer.org.
Chapter
57 ●
Management of Patients With Burn Injury
LEARNING OBJECTIVES
●
On completion of this chapter, the learner will be able to: 1. Discuss the classification system used for burn injuries. 2. Describe the local and systemic effects of a major burn injury. 3. Describe the three phases of burn care and the priorities of care for 4. 5. 6. 7.
each phase. Compare and contrast the potential fluid and electrolyte alterations of the emergent/resuscitative and acute phases of burn management. Describe the goals of the following aspects of burn wound care and the nurse’s role in each: wound cleaning, topical antibacterial therapy, wound dressing, dressing changes, wound débridement, and wound grafting Describe the nurse’s role in the following areas of management: pain management, restrictions of activity and joint motion, psychological support of the patient and family, nutritional support, pulmonary care, and patient and family education. Use the nursing process as a framework for care of the patient during the three phases of burn care.
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T
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INTEGUMENTARY FUNCTION
he nurse who cares for a patient with a burn injury requires a high level of knowledge about the physiologic changes that occur after a burn, as well as astute assessment skills to detect subtle changes in the patient’s condition. In addition, the nurse must be able to provide sensitive, compassionate care to patients who are critically ill and must initiate rehabilitation early in the course of care. The nurse must also be able to communicate effectively with burn patients, distraught family members, and members of the entire interdisciplinary burn management team. This will ensure quality care, which increases the likelihood of the patient’s survival and promotes optimal quality of life.
Incidence of Burn Injury The incidence of burn injuries has been declining during the past several decades. Approximately 2 million people require medical attention for burn injury in the United States each year (Kao & Garner, 2000). Of this group, 51,000 require acute hospital admission. About 4,500 people die from burns and related inhalation injuries annually (American Burn Association, 2000). The risk of death increases significantly if the patient has sustained both a cutaneous burn injury and a smoke inhalation injury. Young children and elderly people are at particularly high risk for burn injury. The skin in people in these two age groups is thin and fragile; therefore, even a limited period of contact with a source of heat can create a full-thickness burn. The National Center for Injury Prevention and Control lists “fire/burn” among the categories of the 1998 Unintentional Injuries and Adverse Effects. Chart 57-1 presents the ranking of “fire/burn” as cause of death by age group. Most burn injuries occur in the home, usually in the kitchen while cooking and in the bathroom by means of scalds or improper use of electrical appliances around water sources (Gordon & Goodwin, 1997). Careless cooking is one of the leading causes of household fires in the United States. The U.S. Fire Administration reports that nearly one third of all residential fires begin in the kitchen. The major factors contributing to cooking fires include unattended cooking, grease, and combustible materials on the stovetop. Burns can also occur from work-related injuries. Education to prevent burn injuries in the workplace should include safe handling
Chart 57-1
Ranking of “Fire/Burn” as Cause of Death by Age Group
Age
Rank
1–4 5–9 10–14 15–24 25–34 35–44 45–54 55–64 65–85+ All ages, all races, both sexes
3 3 3 7 6 5 5 6 6 7
Unintentional Injuries and Adverse Effects, from National Center for Injury Prevention and Control, 1998.
of chemicals and chemical products and increasing awareness of the potential for injuries caused by hot objects and substances. The National Institute for Burn Medicine, which collects statistical data from burn centers throughout the United States, notes that most patients (75%) are victims of their own actions. Contributing to the statistics are scalds in toddlers, school-age children playing with matches, electrical injury in teenage boys, and smoking in adults combined with the use of drugs and alcohol. One of the major culprits of burn injuries is the inappropriate use of gasoline. The U.S. Home Product Report, 1993–1997 (2000), indicated that there were over 140,000 gasoline-related fires and approximately 500 people died from gasoline-related injuries during this period. Many burns can be prevented. Nurses can play an active role in preventing fires and burns by teaching prevention concepts and promoting legislation related to fire safety (Chart 57-2). Promoting the use of smoke alarms has had the greatest impact on decreasing fire deaths in the United States. There are four major goals relating to burns: 1. Prevention 2. Institution of lifesaving measures for the severely burned person
Glossary Alloderm: processed dermis from human cadaver skin; can be used as dermal layer for skin grafts autograft: a graft derived from one part of a patient’s body and used on another part of that same patient’s body Biobrane: synthetic dressing composed of a nylon, Silastic membrane combined with a collagen derivative carboxyhemoglobin: a compound of carbon monoxide and hemoglobin, formed in the blood with exposure to carbon monoxide collagen: a protein present in skin, tendon, bone, cartilage, and connective tissue contracture: shrinkage of burn scar through collagen maturation cultured epithelial autografts (CEA): autologous epidermal cells that proliferate in
culture and then are regrafted onto the patient dermis: the second layer of skin containing sweat glands, hair follicles, and nerves débridement: removal of foreign material and devitalized tissue until surrounding healthy tissue is exposed donor site: the area from which skin is taken to provide a skin graft for another part of the body epidermis: the outermost layer of skin eschar: devitalized tissue resulting from a burn escharotomy: a linear excision made through eschar to release constriction of underlying tissue excision: surgical removal of tissue
fasciotomy: an incision made through the fascia to release constriction of underlying muscle heterograft: graft obtained from an animal of a species (ie, pigskin) other than that of the recipient; also called a xenograft homograft: a graft transferred from one human (living or cadaveric) to another human; also called allograft hydrotherapy: cleansing of wounds through use of bath, shower, shower cart table, or immersion hypertrophic scar: excessive scar formation that rises above the level of the skin Integra: synthetic dermal substitute rule of nines: method for calculating body surface area burned by dividing the body into multiples of nine
Chapter 57
Chart 57-2
Burn Prevention Tips
• Keep matches and lighters out of the reach of children. • Never leave children unattended around fire or in bathroom/bathtub.
• Install and maintain smoke detectors in the home. • Develop and practice a home exit fire drill with all members of the household. Set the water heater temperature no higher than 120°F. Do not smoke in bed. Do not fall asleep while smoking. Do not throw flammable liquids onto an already burning fire. Do not use flammable liquids to start fires. Do not remove radiator cap from a hot engine. Watch for overhead electrical wires and underground wires when working outside. • Never store flammable liquids near a fire source, such as a pilot light. • Use caution when cooking. • Keep a working fire extinguisher in your home.
• • • • • •
3. Prevention of disability and disfigurement through early, specialized, individualized treatment 4. Rehabilitation through reconstructive surgery and rehabilitative programs
Outlook for Survival and Recovery Great strides in research have helped to increase the survival rate of burn victims. Mortality has fallen to levels never thought possible. Hunt et al. (2000) reported that survival following large burns based on total body surface area (TBSA) appears to have leveled off. Persons older than 70 years are surviving burns of 30% TBSA; those 60 to 70 years of age, 50% TBSA; those 20 to 30 years of age, 80% TBSA; and those 2 to 5 years of age, 75% TBSA. Research in areas such as fluid resuscitation, emergent burn treatment, inhalation injury treatment, and changes in wound care practice with early débridement and excision have contributed greatly to the decrease in burn deaths. Additionally, a better understanding of the importance of adequate nutritional support has contributed to increased survival rates. Very young and very old people have a high risk of death after burn injuries due to immature and stressed immunologic systems and pre-existing medical conditions, respectively. Chances of survival are greater in children older than age 5 and in adults younger than age 40. Inhalation injuries in combination with cutaneous burns worsen the prognosis. Outcome depends on the depth and extent of the burn as well as on the pre-injury health status and age of the patient. Acute care of patients with burn injuries has improved to the point at which survival is expected for most patients, and the burn team has shifted its focus to long-term outcomes for these patients. Gerontologic Considerations Reduced mobility, changes in vision, and decreased sensation in the feet and hands place elderly people at higher risk for burn injury; scalds and flames are the leading causes. These changes also place older people at risk for suffering a severe burn because they have difficulty in extinguishing the fire and removing themselves from the burn source. Morbidity and mortality rates associated with burns are usually greater in elderly patients than in younger patients. Thinning
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and loss of elasticity of the skin in the elderly predispose them to a deep injury from a thermal insult that might cause a less severe burn in a younger person. Moreover, chronic illnesses decrease the older person’s ability to withstand the multisystem stresses imposed by burn injury. An important goal of nurses in community and home settings is preventing burn injury, especially among the elderly. Nurses need to assess an elderly patient’s ability to perform activities of daily living safely, assist elderly patients and families to modify the environment to ensure safety, and make referrals as needed.
Pathophysiology of Burns Burns are caused by a transfer of energy from a heat source to the body. Heat may be transferred through conduction or electromagnetic radiation. Burns are categorized as thermal (which includes electrical burns), radiation, or chemical. Tissue destruction results from coagulation, protein denaturation, or ionization of cellular contents. The skin and the mucosa of the upper airways are the sites of tissue destruction. Deep tissues, including the viscera, can be damaged by electrical burns or through prolonged contact with a heat source. Disruption of the skin can lead to increased fluid loss, infection, hypothermia, scarring, compromised immunity, and changes in function, appearance, and body image. The depth of the injury depends on the temperature of the burning agent and the duration of contact with the agent. For example, in the case of scald burns in adults, 1 second of contact with hot tap water at 68.9°C (156°F) may result in a burn that destroys both the epidermis and the dermis, causing a fullthickness (third-degree) injury. Fifteen seconds of exposure to hot water at 56.1°C (133°F) results in a similar full-thickness injury. Temperatures less than 111°F are tolerated for long periods without injury.
CLASSIFICATION OF BURNS Burn injuries are described according to the depth of the injury and the extent of body surface area injured.
Burn Depth Burns are classified according to the depth of tissue destruction as superficial partial-thickness injuries, deep partial-thickness injuries, or full-thickness injuries. Burn depth determines whether epithelialization will occur. Determining burn depth can be difficult even for the experienced burn care provider. See Chapter 56 for discussion and a diagram of the skin layers; see also Table 57-1. (The categories of superficial partial-thickness, deep partial-thickness, and full-thickness burns are similar to, but not the same as, first-, second-, and third-degree burns.) In a superficial partial-thickness burn, the epidermis is destroyed or injured and a portion of the dermis may be injured. The damaged skin may be painful and appear red and dry, as in sunburn, or it may blister. A deep partial-thickness burn involves destruction of the epidermis and upper layers of the dermis and injury to deeper portions of the dermis. The wound is painful, appears red, and exudes fluid. Capillary refill follows tissue blanching. Hair follicles remain intact. Deep partial-thickness burns take longer to heal and are more likely to result in hypertrophic scars. A full-thickness burn involves total destruction of epidermis and dermis and, in some cases, underlying tissue as well. Wound color ranges widely from white to red, brown, or black. The burned area
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Table 57-1
INTEGUMENTARY FUNCTION
• Characteristics of Burns According to Depth
DEPTH OF BURN AND CAUSES
SKIN INVOLVEMENT
SYMPTOMS
Superficial Partial-Thickness (Similar to First Degree) Sunburn Epidermis; possibly a Tingling Hyperesthesia Low-intensity flash portion of dermis (supersensitivity) Pain that is soothed by cooling Deep Partial-Thickness (Similar to Second Degree) Pain Scalds Epidermis, upper Hyperesthesia Flash flame dermis, portion of Sensitive to cold air deeper dermis
Full-Thickness (Similar to Third Degree) Flame Epidermis, entire derProlonged exposure to mis, and sometimes hot liquids subcutaneous tissue; Electric current may involve connecChemical tive tissue, muscle, and bone
Pain free Shock Hematuria (blood in the urine) and possibly hemolysis (blood cell destruction) Possible entrance and exit wounds (electrical burn)
is painless because nerve fibers are destroyed. The wound appears leathery; hair follicles and sweat glands are destroyed (Fig. 57-1). The following factors are considered in determining the depth of the burn:
• • • • •
How the injury occurred Causative agent, such as flame or scalding liquid Temperature of the burning agent Duration of contact with the agent Thickness of the skin
Extent of Body Surface Area Injured Various methods are used to estimate the TBSA affected by burns; among them are the rule of nines, the Lund and Browder method, and the palm method.
Zone of hyperemia
WOUND APPEARANCE
RECUPERATIVE COURSE
Reddened; blanches with pressure; dry Minimal or no edema Possible blisters
Complete recovery within a week; no scarring Peeling
Blistered, mottled red base; broken epidermis; weeping surface Edema
Recovery in 2 to 4 weeks Some scarring and depigmentation contractures Infection may convert it to full thickness
Dry; pale white, leathery, or charred Broken skin with fat exposed Edema
Eschar sloughs Grafting necessary Scarring and loss of contour and function; contractures Loss of digits or extremity possible
RULE OF NINES An estimation of the TBSA involved in a burn is simplified by using the rule of nines (Fig. 57-2). The rule of nines is a quick way to calculate the extent of burns. The system assigns percentages in multiples of nine to major body surfaces. LUND AND BROWDER METHOD A more precise method of estimating the extent of a burn is the Lund and Browder method, which recognizes that the percentage of TBSA of various anatomic parts, especially the head and legs, and changes with growth. By dividing the body into very small areas and providing an estimate of the proportion of TBSA accounted for by such body parts, one can obtain a reliable estimate of the TBSA burned. The initial evaluation is made on the patient’s arrival at the hospital and is revised on the second and third post-burn days because the demarcation usually is not clear until then. PALM METHOD In patients with scattered burns, a method to estimate the percentage of burn is the palm method. The size of the patient’s palm is approximately 1% of TBSA.
Zone of stasis Zone of coagulation
Skin
LOCAL AND SYSTEMIC RESPONSES TO BURNS
Subcutaneous tissue
Burns that do not exceed 25% TBSA produce a primarily local response. Burns that exceed 25% TBSA may produce both a local and a systemic response and are considered major burn injuries. This systemic response is due to the release of cytokines and other mediators into the systemic circulation. The release of local mediators and changes in blood flow, tissue edema, and infection can cause progression of the burn injury. Pathophysiologic changes resulting from major burns during the initial burn-shock period include tissue hypoperfusion and organ hypofunction secondary to decreased cardiac output, followed by a hyperdynamic and hypermetabolic phase. The incidence, magnitude, and duration of pathophysiologic changes in
FIGURE 57-1 Zones of burn injury. Each burned area has three zones of injury. The inner zone (known as the area of coagulation, where cellular death occurs) sustains the most damage. The middle area, or zone of stasis, has a compromised blood supply, inflammation, and tissue injury. The outer zone—the zone of hyperemia—sustains the least damage.
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Anterior 18% Posterior 18%
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sure) remain low during the burn-shock period. If inadequate fluid resuscitation occurs, distributive shock will occur (see Chap. 15). Generally, the greatest volume of fluid leak occurs in the first 24 to 36 hours after the burn, peaking by 6 to 8 hours. As the capillaries begin to regain their integrity, burn shock resolves and fluid returns to the vascular compartment. As fluid is reabsorbed from the interstitial tissue into the vascular compartment, blood volume increases. If renal and cardiac function is adequate, urinary output increases. Diuresis continues for several days to 2 weeks.
9%
9%
Management of Patients With Burn Injury
9%
1% 18% 18%
FIGURE 57-2 The rule of nines: Estimated percentage of total body surface area (TBSA) in the adult is arrived at by sectioning the body surface into areas with a numerical value related to nine. (Note: The anterior and posterior head total 9% of TBSA.) In burn victims, the total estimated percentage of TBSA injured is used to calculate the patient’s fluid replacement needs. burns are proportional to the extent of burn injury, with a maximal response seen in burns covering 60% or more TBSA. The initial systemic event after a major burn injury is hemodynamic instability, resulting from loss of capillary integrity and a subsequent shift of fluid, sodium, and protein from the intravascular space into the interstitial spaces. Figure 57-3 illustrates the pathophysiologic processes in acute major burns. Hemodynamic instability involves cardiovascular, fluid and electrolyte, blood volume, pulmonary, and other mechanisms.
Cardiovascular Response Hypovolemia is the immediate consequence of fluid loss resulting in decreased perfusion and oxygen delivery. Cardiac output decreases before any significant change in blood volume is evident. As fluid loss continues and vascular volume decreases, cardiac output continues to fall and blood pressure drops. This is the onset of burn shock. In response, the sympathetic nervous system releases catecholamines, resulting in an increase in peripheral resistance (vasoconstriction) and an increase in pulse rate. Peripheral vasoconstriction further decreases cardiac output. Myocardial contractility may be suppressed by the release of inflammatory cytokine necrosis factor (Wolf, Prough & Herndon, 2002). Prompt fluid resuscitation maintains the blood pressure in the low-normal range and improves cardiac output. Despite adequate fluid resuscitation, cardiac filling pressures (central venous pressure, pulmonary artery pressure, and pulmonary artery wedge pres-
Burn Edema Local swelling due to thermal injury is often extensive. Edema is defined as the presence of excessive fluid in the tissue spaces (Lund, 1999). As previously noted, in burns involving less than 25% TBSA, the loss of capillary integrity and shift of fluid are localized to the burn itself, resulting in blister formation and edema only in the area of injury. Patients with more severe burns develop massive systemic edema. Edema is usually maximal after 24 hours. It begins to resolve 1 to 2 days post-burn and usually is completely resolved in 7 to 10 days post-injury. Edema in burn wounds can be reduced by avoiding excessive fluid during the early post-burn period. Unnecessary over-resuscitation will increase edema formation in both burn tissue and non-burn tissue. As edema increases in circumferential burns, pressure on small blood vessels and nerves in the distal extremities causes an obstruction of blood flow and consequent ischemia. This complication is known as compartment syndrome. The physician may need to perform an escharotomy, a surgical incision into the eschar (devitalized tissue resulting from a burn), to relieve the constricting effect of the burned tissue.
Effects on Fluids, Electrolytes, and Blood Volume Circulating blood volume decreases dramatically during burn shock. In addition, evaporative fluid loss through the burn wound may reach 3 to 5 L or more over a 24-hour period until the burn surfaces are covered. During burn shock, serum sodium levels vary in response to fluid resuscitation. Usually hyponatremia (sodium depletion) is present. Hyponatremia is also common during the first week of the acute phase, as water shifts from the interstitial to the vascular space. Immediately after burn injury, hyperkalemia (excessive potassium) results from massive cell destruction. Hypokalemia (potassium depletion) may occur later with fluid shifts and inadequate potassium replacement. At the time of burn injury, some red blood cells may be destroyed and others damaged, resulting in anemia. Despite this, the hematocrit may be elevated due to plasma loss. Blood loss during surgical procedures, wound care, and diagnostic studies and ongoing hemolysis further contribute to anemia. Blood transfusions are required periodically to maintain adequate hemoglobin levels for oxygen delivery. Abnormalities in coagulation, including a decrease in platelets (thrombocytopenia) and prolonged clotting and prothrombin times, also occur with burn injury.
Pulmonary Response Inhalation injury is the leading cause of death in fire victims. It is estimated that half of these deaths could have been prevented with use of a smoke detector. Often, burn victims make it out of
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Physiology/Pathophysiology
Major Burns >30% TBSA Cell lysis
Hemolysis
Capillary permeability
Hyperkalemia
Thermoregulation problems
Sodium, H2O and protein shift from intravascular to interstitial spaces
Hemoglobin/ myoglobin in urine
Loss of skin barrier
Possible inhalation injury
Hyponatremia
Concentration of red blood cells
Inflammatory response
Impaired immune response
Circulating Blood Volume (up to 50%)
Blood viscosity
Burn shock
Massive stress response, sympathetic nervous system activation
Myocardial depressant factor
Blood pressure Hypoxemia
Adrenal corticoid hormones and catecholamine release
Peripheral vasoconstriction
Tachycardia
Hyperglycemia
Catabolism
Risk of Curling's ulcer
Metabolism (after burn shock resolves)
Afterload
Cardiac output Tissue Perfusion Renal blood flow
GI blood flow
Anaerobic metabolism
Tissue damage
Cellular dysfunction
Risk of acute renal failure
Risk of ileus
Metabolic acidosis
Potential tissue necrosis
Cell swelling
FIGURE 57-3
Overview of physiologic changes that occur after major burn.
Chapter 57 a burning home safely. However, once they are outside, they may realize that their loved ones, pets, or valuable items are still inside the burning home. They then re-enter the burning home and are overcome with toxic smoke and fumes and become disoriented or unconscious. Inhalation injury has a significant impact on survivability of a burn patient. Deterioration in severely burned patients can occur without evidence of a smoke inhalation injury. Bronchoconstriction caused by release of histamine, serotonin, and thromboxane, a powerful vasoconstrictor, as well as chest constriction secondary to circumferential full-thickness chest burns causes this deterioration. One third of all burn patients have a pulmonary problem related to the burn injury (Flynn, 1999). Even without pulmonary injury, hypoxia (oxygen starvation) may be present. Early in the postburn period, catecholamine release in response to the stress of the burn injury alters peripheral blood flow, thereby reducing oxygen delivery to the periphery. Later, hypermetabolism and continued catecholamine release lead to increased tissue oxygen consumption, which can lead to hypoxia. To ensure that adequate oxygen is available to the tissues, supplemental oxygen may be needed. Pulmonary injuries fall into several categories: upper airway injury; inhalation injury below the glottis, including carbon monoxide poisoning; and restrictive defects. Upper airway injury results from direct heat or edema. It is manifested by mechanical obstruction of the upper airway, including the pharynx and larynx. Because of the cooling effect of rapid vaporization in the pulmonary tract, direct heat injury does not normally occur below the level of the bronchus. Upper airway injury is treated by early nasotracheal or endotracheal intubation. Inhalation injury below the glottis results from inhaling the products of incomplete combustion or noxious gases. These products include carbon monoxide, sulfur oxides, nitrogen oxides, aldehydes, cyanide, ammonia, chlorine, phosgene, benzene, and halogens. The injury results directly from chemical irritation of the pulmonary tissues at the alveolar level. Inhalation injuries below the glottis cause loss of ciliary action, hypersecretion, severe mucosal edema, and possibly bronchospasm. The pulmonary surfactant is reduced, resulting in atelectasis (collapse of alveoli). Expectoration of carbon particles in the sputum is the cardinal sign of this injury. Carbon monoxide is probably the most common cause of inhalation injury because it is a byproduct of the combustion of organic materials and is therefore present in smoke. The pathophysiologic effects are due to tissue hypoxia, a result of carbon monoxide combining with hemoglobin to form carboxyhemoglobin, which competes with oxygen for available hemoglobinbinding sites. The affinity of hemoglobin for carbon monoxide is 200 times greater than that for oxygen. Treatment usually consists of early intubation and mechanical ventilation with 100% oxygen. However, some patients may require only oxygen therapy, depending on the extent of pulmonary injury and edema. Administering 100% oxygen is essential to accelerate the removal of carbon monoxide from the hemoglobin molecule. Restrictive defects arise when edema develops under fullthickness burns encircling the neck and thorax. Chest excursion may be greatly restricted, resulting in decreased tidal volume. In such situations, escharotomy is necessary. Pulmonary abnormalities are not always immediately apparent. More than half of all burn victims with pulmonary involvement do not initially demonstrate pulmonary signs and symptoms. Any patient with possible inhalation injury must be observed for at least 24 hours for respiratory complications. Airway obstruction may
Management of Patients With Burn Injury
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occur very rapidly or develop in hours. Decreased lung compliance, decreased arterial oxygen levels, and respiratory acidosis may occur gradually over the first 5 days after a burn. Indicators of possible pulmonary damage include the following:
• History indicating that the burn occurred in an enclosed • • • • • •
area Burns of the face or neck Singed nasal hair Hoarseness, voice change, dry cough, stridor, sooty sputum Bloody sputum Labored breathing or tachypnea (rapid breathing) and other signs of reduced oxygen levels (hypoxemia) Erythema and blistering of the oral or pharyngeal mucosa
Diagnosis of inhalation injury is an important priority for many burn victims. Serum carboxyhemoglobin levels and arterial blood gas levels are frequently used to assess for inhalation injuries. Bronchoscopy and xenon-133 (133Xe) ventilation-perfusion scans can also be used to aid diagnosis in the early postburn period. Pulmonary function studies may also be useful in diagnosing decreased lung compliance or obstructed airflow (Fitzpatrick & Cioffi, 2002; Flynn, 1999). Pulmonary complications secondary to inhalation injuries include acute respiratory failure and acute respiratory distress syndrome (ARDS). Respiratory failure occurs when impairment of ventilation and gas exchange is life-threatening. The immediate intervention is intubation and mechanical ventilation. If ventilation is impaired by restricted chest excursion, immediate chest escharotomy is needed. ARDS may develop in the first few days after the burn injury secondary to systemic and pulmonary responses to the burn and inhalation injury. Respiratory failure and ARDS are discussed in Chapter 23.
Other Systemic Responses Renal function may be altered as a result of decreased blood volume. Destruction of red blood cells at the injury site results in free hemoglobin in the urine. If muscle damage occurs (eg, from electrical burns), myoglobin is released from the muscle cells and excreted by the kidney. Adequate fluid volume replacement restores renal blood flow, increasing the glomerular filtration rate and urine volume. If there is inadequate blood flow through the kidneys, the hemoglobin and myoglobin occlude the renal tubules, resulting in acute tubular necrosis and renal failure (see Chap. 45). The immunologic defenses of the body are greatly altered by burn injury. Serious burn injury diminishes resistance to infection. As a result, sepsis remains the leading cause of death in thermally injured patients (Cioffi, 2001). The loss of skin integrity is compounded by the release of abnormal inflammatory factors, altered levels of immunoglobulins and serum complement, impaired neutrophil function, and a reduction in lymphocytes (lymphocytopenia). Research suggests that burn injury results in loss of T-helper cell lymphocytes (Munster, 2002). There is a significant impairment of the production and release of granulocytes and macrophages from bone marrow after burn injury. The resulting immunosuppression places the burn patient at high risk for sepsis. Loss of skin also results in an inability to regulate body temperature. Burn patients may therefore exhibit low body temperatures in the early hours after injury. Then, as hypermetabolism resets core temperatures, burn patients become hyperthermic for much of the postburn period, even in the absence of infection.
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Two potential gastrointestinal complications may occur: paralytic ileus (absence of intestinal peristalsis) and Curling’s ulcer. Decreased peristalsis and bowel sounds are manifestations of paralytic ileus resulting from burn trauma. Gastric distention and nausea may lead to vomiting unless gastric decompression is initiated. Gastric bleeding secondary to massive physiologic stress may be signaled by occult blood in the stool, regurgitation of “coffee ground” material from the stomach, or bloody vomitus. These signs suggest gastric or duodenal erosion (Curling’s ulcer).
• Airway • Breathing • Circulation; cervical spine immobilization for patients with
high-voltage electrical injuries and if indicated for other injuries; cardiac monitoring for patients with all electrical injuries for at least 24 hours after cessation of dysrhythmia
Some practitioners include “DEF” in the trauma assessment: disability, exposure, and fluid resuscitation (Weibelhaus & Hansen, 2001).
Management of the Patient With a Burn Injury Burn care must be planned according to the burn depth and local response, the extent of the injury, and the presence of a systemic response. Burn care then proceeds through three phases: emergent/ resuscitative phase, acute/intermediate phase, and rehabilitation phase. Although priorities exist for each of the phases, the phases overlap, and assessment and management of specific problems and complications are not limited to these phases but take place throughout burn care. The three phases and the priorities for care are summarized in Table 57-2.
EMERGENT/RESUSCITATIVE PHASE OF BURN CARE On-the-Scene Care Anyone who encounters a burn victim for the first time may feel overwhelmed. The burned person’s appearance can be frightening at first. It can be difficult not to get caught up with the appearance of the person and instead to concentrate on the burn wounds. However, the burn wound is not the first priority at the scene: the first priority of on-the-scene care for a burn victim is to prevent injury to the rescuer. If needed, fire and emergency medical services should be requested at the first opportunity. Additional emergency procedures are highlighted in Chart 57-3. AIRWAY, BREATHING, CIRCULATION Although the local effects of a burn are the most evident, the systemic effects pose a greater threat to life. Therefore, it is important to remember the ABCs of all trauma care during the early postburn period:
Table 57-2
!
NURSING ALERT Breathing must be assessed and a patent airway established immediately during the initial minutes of emergency care. Immediate therapy is directed toward establishing an airway and administering humidified 100% oxygen. If such a high concentration of oxygen is not available under emergency conditions, oxygen by mask or nasal cannula is given initially. If qualified personnel and equipment are available and if the victim has severe respiratory distress or airway edema, the rescuers can insert an endotracheal tube and initiate manual ventilation.
The circulatory system must also be assessed quickly. Apical pulse and blood pressure are monitored frequently. Tachycardia (abnormally rapid heart rate) and slight hypotension are expected soon after the burn. The neurologic status is assessed quickly in the patient with extensive burns. Often the burn patient is awake and alert initially, and vital information can be obtained at that time. A secondary head-to-toe survey of the patient is carried out to identify other potentially life-threatening injuries. (The E and F parameters of trauma assessment are discussed in detail later.) Preventing shock in a burn patient is imperative.
!
NURSING ALERT No food or fluid is given by mouth, and the patient is placed in a position that will prevent aspiration of vomitus because nausea and vomiting typically occur due to paralytic ileus resulting from the stress of injury.
Usually, rescue workers will cool the wound, establish an airway, supply oxygen, and insert at least one large-bore intravenous line.
• Phases of Burn Care
PHASE
DURATION
PRIORITIES
Emergent or immediate resuscitative
From onset of injury to completion of fluid resuscitation
Acute
From beginning of diuresis to near completion of wound closure
Rehabilitation
From major wound closure to return to individual’s optimal level of physical and psychosocial adjustment
• First aid • Prevention of shock • Prevention of respiratory distress • Detection and treatment of concomitant injuries • Wound assessment and initial care • Wound care and closure • Prevention or treatment of complications, including infection • Nutritional support • Prevention of scars and contractures • Physical, occupational, and vocational rehabilitation • Functional and cosmetic reconstruction • Psychosocial counseling
Chapter 57
Chart 57-3
Emergency Procedures at the Burn Scene
• Extinguish the flames. When clothes catch fire, the flames can
•
•
•
•
be extinguished if the victim falls to the floor or ground and rolls (“drop and roll”); anything available to smother the flames, such as a blanket, rug, or coat, may be used. Standing still forces the victim to breathe flames and smoke, and running fans the flames. If the burn source is electrical, the electrical source must be disconnected. Cool the burn. After the flames are extinguished, the burned area and adherent clothing are soaked with cool water, briefly, to cool the wound and halt the burning process. Once a burn has been sustained, the application of cool water is the best first-aid measure. Soaking the burn area intermittently in cool water or applying cool towels gives immediate and striking relief from pain and limits local tissue edema and damage. However, never apply ice directly to the burn, never wrap burn victims in ice, and never use cold soaks or dressings for longer than several minutes; such procedures may worsen the tissue damage and lead to hypothermia in patients with large burns. Remove restrictive objects. If possible, remove clothing immediately. Adherent clothing may be left in place once cooled. Other clothing and all jewelry should be removed to allow for assessment and to prevent constriction secondary to rapidly developing edema. Cover the wound. The burn should be covered as quickly as possible to minimize bacterial contamination and decrease pain by preventing air from coming into contact with the injured surface. Sterile dressings are best, but any clean, dry cloth can be used as an emergency dressing. Ointments and salves should not be used. Other than the dressing, no medication or material should be applied to the burn wound. Irrigate chemical burns. Chemical burns resulting from contact with a corrosive material are irrigated immediately. Most chemical laboratories have a high-pressure shower for such emergencies. If such an injury occurs at home, brush off the chemical agent, remove clothes immediately, and rinse all areas of the body that have come in contact with the chemical. Rinsing can occur in the shower or any other source of continuous running water. If a chemical gets in or near the eyes, the eyes should be flushed with cool, clean water immediately. Outcomes for the patient with chemical burns are significantly improved by rapid, sustained flushing of the injury at the scene.
Emergency Medical Management The patient is transported to the nearest emergency department. The hospital and physician are alerted that the patient is en route to the emergency department so that life-saving measures can be initiated immediately by a trained team. Initial priorities in the emergency department remain airway, breathing, and circulation. For mild pulmonary injury, inspired air is humidified and the patient is encouraged to cough so that secretions can be removed by suctioning. For more severe situations, it is necessary to remove secretions by bronchial suctioning and to administer bronchodilators and mucolytic agents. If edema of the airway develops, endotracheal intubation may be necessary. Continuous positive airway pressure and mechanical ventilation may also be required to achieve adequate oxygenation.
Management of Patients With Burn Injury
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After adequate respiratory status and circulatory status have been established, the patient is assessed for cervical spinal injuries or head injury if the patient was involved in an explosion, a fall, a jump, or an electrical injury. Once the patient’s condition is stable, attention is directed to the burn wound itself. All clothing and jewelry are removed. For chemical burns, flushing of the exposed areas is continued. The patient is checked for contact lenses. These are removed immediately if chemicals have contacted the eyes or if facial burns have occurred. It is important to validate an account of the burn scenario provided by the patient, witnesses at the scene, and paramedics. Information needs to include time of the burn injury, source of the burn, place where the burn occurred, how the burn was treated at the scene, and any history of falling with the injury. A history of preexisting diseases, allergies, and medications and the use of drugs, alcohol, and tobacco is obtained at this point to plan care. A large-bore (16- or 18-gauge) intravenous catheter should be inserted in a non-burned area (if not inserted earlier). Most patients have a central venous catheter inserted so that large amounts of intravenous fluids can be given quickly and central venous pressures can be monitored. If the burn exceeds 25% TBSA or if the patient is nauseated, a nasogastric tube should be inserted and connected to suction to prevent vomiting due to paralytic ileus (absence of peristalsis). The physician evaluates the patient’s general condition, assesses the burn, determines the priorities of care, and directs the individualized plan of treatment, which is divided into systemic management and local care of the burned area. Nonsterile gloves, caps, and gowns are worn by personnel while assessing the exposed burned areas. Clean technique is maintained while assessing burn wounds. Assessment of both the TBSA burned and the depth of the burn is completed after soot and debris have been gently cleansed from the burn wound. Careful attention is paid to keeping the burn patient warm during wound assessment and cleansing. Assessment is repeated frequently throughout burn wound care. Photographs may be taken of the burn areas initially and periodically throughout treatment; in this way, the initial injury and burn wound can be documented. Such documentation is invaluable for insurance and legal claims. Clean sheets are placed under and over the patient to protect the area from contamination, maintain body temperature, and reduce pain caused by air currents passing over exposed nerve endings. An indwelling urinary catheter is inserted to permit more accurate monitoring of urine output and renal function for patients with moderate to severe burns. Baseline height, weight, arterial blood gases, hematocrit, electrolyte values, blood alcohol level, drug panel, urinalysis, and chest x-rays are obtained. If the patient is elderly or has an electrical burn, a baseline electrocardiogram is obtained. Because burns are contaminated wounds, tetanus prophylaxis is administered if the patient’s immunization status is not current or is unknown. Although the major focus of care during the emergent phase is physical stabilization, the nurse must also attend to the patient’s and family’s psychological needs. Burn injury is a crisis, causing variable emotional responses. The patient’s and family’s coping abilities and available supports are assessed. Circumstances surrounding the burn injury should be considered when providing care. Individualized psychosocial support must be given to the patient and family. Because the emergent burn patient is usually anxious and in pain, those in attendance should provide reassurance and support, explanations of procedures, and adequate pain relief. Because poor tissue perfusion accompanies burn injuries,
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only intravenous pain medication (usually morphine) is given, titrated for the patient. If the patient wishes to see a spiritual advisor, one is notified. TRANSFER TO A BURN CENTER The depth and extent of the burn are considered in determining whether the patient should be transferred to a burn center. Patients with major burns, those who are at the extremes of the age continuum, those with coexisting health problems that may affect recovery, and those with circumstances that increase their risk for acute and long-term complications are transferred to a burn center. Chart 57-4 lists the American Burn Association’s criteria for burn center referral after initial assessment and management. If the patient is to be transported to a burn center, the following measures are instituted before transfer:
• A secure intravenous catheter is inserted with lactated • • • •
Ringer’s solution infusing at the rate required to maintain a urine output of at least 30 mL per hour. A patent airway is ensured. Adequate pain relief is attained. Adequate peripheral circulation is established in any burned extremity. Wounds are covered with a clean, dry sheet, and the patient is kept comfortably warm.
All assessments and treatments are documented, and this information is provided to the burn center personnel. The transferring facility must relay accurate intake and output totals to burn center personnel so that adequate fluid resuscitation measures continue.
Chart 57-4
Criteria for Classifying the Extent of Burn Injury (American Burn Association)
Minor Burn Injury • Second-degree burn of less than 15% total body surface area (TBSA) in adults or less than 10% TBSA in children • Third-degree burn of less than 2% TBSA not involving special care areas (eyes, ears, face, hands, feet, perineum, joints) • Excludes electrical injury, inhalation injury, concurrent trauma, all poor-risk patients (eg, extremes of age, concurrent disease) Moderate, Uncomplicated Burn Injury • Second-degree burns of 15%–25% TBSA in adults or 10%–20% in children • Third-degree burns of less than 10% TBSA not involving special care areas • Excludes electrical injury, inhalation injury, concurrent trauma, all poor-risk patients (eg, extremes of age, concurrent disease) Major Burn Injury • Second-degree burns exceeding 25% TBSA in adults or 20% in children • All third-degree burns exceeding 10% TBSA • All burns involving eyes, ears, face, hands, feet, perineum, joints • All inhalation injury, electrical injury, concurrent trauma, all poor-risk patients From Hudak, C. M., Gallo, B. M., & Morton, P. G. (1998). Critical care nursing: A holistic approach (7th ed.). Philadelphia: Lippincott Williams & Wilkins.
MANAGEMENT OF FLUID LOSS AND SHOCK Next to handling respiratory difficulties, the most urgent need is preventing irreversible shock by replacing lost fluids and electrolytes. As mentioned previously, survival of burn victims depends on adequate fluid resuscitation. Table 57-3 summarizes the fluid and electrolyte changes in the emergent phase of burn care. Intravenous lines and an indwelling catheter must be in place before implementing fluid resuscitation. Baseline weight and laboratory test results are obtained as well. These parameters must be monitored closely in the immediate post-burn (resuscitation) period. Controversy continues regarding the definition of adequate resuscitation and the optimal fluid type for resuscitation. Refinement of resuscitation techniques remains an active area of burn research. Fluid Replacement Therapy. The total volume and rate of intravenous fluid replacement are gauged by the patient’s response. The adequacy of fluid resuscitation is determined by following urine output totals, an index of renal perfusion. Output totals of 30 to 50 mL/hour have been used as goals. Other indicators of adequate fluid replacement are a systolic blood pressure exceeding 100 mm Hg and/or a pulse rate less than 110/minute.
!
NURSING ALERT Clinical parameters are far more important in resuscitation than any formula. Indeed, the patient’s individual response is the key to assessing the adequacy of fluid resuscitation.
Additional gauges of fluid requirements and response to fluid resuscitation include hematocrit and hemoglobin and serum sodium levels. If the hematocrit and the hemoglobin levels decrease or if the urinary output exceeds 50 mL/hour, the rate of intravenous fluid administration may be decreased. The goal is to maintain serum sodium levels in the normal range during fluid replacement. Appropriate resuscitation endpoints for burn patients remain controversial. Research in this area has led to the study of hemodynamic and oxygen transport resuscitation endpoints. When these endpoints were used, massive fluid resuscitation volumes were administered that could have deleterious effects. Successful resuscitation is associated with increased delivery of oxygen and consumption of oxygen with declining serum lactate levels (Holm et al., 2000). Attention has been directed recently toward other indicators of adequate resuscitation: base deficit and serum lactate levels. Measurement of serum lactate levels does not appear useful in the treatment of burn patients because of the large amounts of lactate released from burned tissue; however, metabolism of lactate is unaltered. Elevated levels occur despite adequate fluid resuscitation (Yowler & Fratianne, 2000). Factors that are associated with the increased fluid requirements include delayed resuscitation, scald burn injuries, inhalation injuries, high-voltage electrical injuries, hyperglycemia, alcohol intoxication, and chronic diuretic therapy. Second 24-hour post-burn fluid infusion rates incorporate both the maintenance amount of fluid and any additional fluid needs secondary to evaporative water loss through the burn wound. Fluid Requirements. The projected fluid requirements for the first 24 hours are calculated by the clinician based on the extent of the burn injury. Some combination of fluid categories may be used: colloids (whole blood, plasma, and plasma expanders) and crystalloids/electrolytes (physiologic sodium chloride or lactated
Chapter 57
Table 57-3
Management of Patients With Burn Injury
1713
• Fluid and Electrolyte Changes in the Emergent/Resuscitative Phase
Fluid accumulation phase (shock phase) Plasma → interstitial fluid (edema at burn site) OBSERVATION
EXPLANATION
Generalized dehydration Reduction of blood volume Decreased urinary output
Plasma leaks through damaged capillaries. Secondary to plasma loss, fall of blood pressure, and diminished cardiac output Secondary to: Fluid loss Decreased renal blood flow Sodium and water retention caused by increased adrenocortical activity (Hemolysis of red blood cells, causing hemoglobinuria and myonecrosis or myoglobinuria) Massive cellular trauma causes release of K+ into extracellular fluid (ordinarily, most K+ is intracellular). Large amount of Na+ is lost in trapped edema fluid and exudate and by shift into cells as K+ is released from cells (ordinarily most Na+ is extracellular). Loss of bicarbonate ions accompanies sodium loss. Liquid blood component is lost into extravascular space.
Potassium (K+) excess Sodium (Na+) deficit Metabolic acidosis (base-bicarbonate deficit) Hemoconcentration (elevated hematocrit)
Ringer’s solution). Adequate fluid resuscitation results in slightly decreased blood volume levels during the first 24 post-burn hours and restores plasma levels to normal by the end of 48 hours. Oral resuscitation can be successful in adults with less than 20% TBSA and children with less than 10% to 15% TBSA. Formulas have been developed for estimating fluid loss based on the estimated percentage of burned TBSA and the weight of the patient. Length of time since burn injury occurred is also very important in calculating estimated fluid needs. Formulas must be adjusted so that initiation of fluid replacement reflects the time of injury. Resuscitation formulas are approximations only and are individualized to meet the requirements of each patient. The various formulas are discussed below and summarized in Chart 57-5.
Chart 57-5
As early as 1978, the NIH Consensus Development Conference on Supportive Therapy in Burn Care established that salt and water are required in burn patients, but that colloid may or may not be useful during the first 24 to 48 post-burn hours. The consensus formula provides for the volume of balanced salt solution to be administered in the first 24 hours in a range of 2 to 4 mL/kg per percent burn. In general, 2 mL/kg per percent burn of lactated Ringer’s solution may be used initially for adults. This is the most common fluid replacement formula in use today. As with the other formulas, half of the calculated total should be given over the first 8 post-burn hours, and the other half should be given over the next 16 hours. The rate and volume of the infusion must be regulated according to the patient’s response by changing the
Guidelines and Formulas for Fluid Replacement in Burn Patients
Consensus Formula Lactated Ringer’s solution (or other balanced saline solution): 2–4 mL × kg body weight × % total body surface area (TBSA) burned. Half to be given in first 8 hours; remaining half to be given over next 16 hours. Evans Formula 1. Colloids: 1 mL × kg body weight × % TBSA burned 2. Electrolytes (saline): 1 mL × body weight × % TBSA burned 3. Glucose (5% in water): 2,000 mL for insensible loss Day 1: Half to be given in first 8 hours; remaining half over next 16 hours Day 2: Half of previous day’s colloids and electrolytes; all of insensible fluid replacement Maximum of 10,000 mL over 24 hours. Second- and third-degree (partial- and full-thickness) burns exceeding 50% TBSA are calculated on the basis of 50% TBSA. Brooke Army Formula 1. Colloids: 0.5 mL × kg body weight × % TBSA burned 2. Electrolytes (lactated Ringer’s solution): 1.5 mL × kg body weight × % TBSA burned 3. Glucose (5% in water): 2,000 mL for insensible loss
Day 1: Half to be given in first 8 hours; remaining half over next 16 hours Day 2: Half of colloids; half of electrolytes; all of insensible fluid replacement. Second- and third-degree (partial- and full-thickness) burns exceeding 50% TBSA are calculated on the basis of 50% TBSA. Parkland/Baxter Formula Lactated Ringer’s solution: 4 mL × kg body weight × % TBSA burned Day 1: Half to be given in first 8 hours; half to be given over next 16 hours Day 2: Varies. Colloid is added. Hypertonic Saline Solution Concentrated solutions of sodium chloride (NaCl) and lactate with concentration of 250–300 mEq of sodium per liter, administered at a rate sufficient to maintain a desired volume of urinary output. Do not increase the infusion rate during the first 8 postburn hours. Serum sodium levels must be monitored closely. Goal: Increase serum sodium level and osmolality to reduce edema and prevent pulmonary complications.
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hourly infusion rates. Fluid boluses are recommended only in the presence of marked hypotension, not low urine output. Typical fluid rate changes should involve an increase or decrease in flow rate by no more than 25% to 33% (Yowler & Fratianne, 2000). Studies demonstrate that with large burns, there is a failure of the sodium-potassium pump (a physiologic mechanism involved in fluid–electrolyte balance) at the cellular level. Thus, patients with very large burns may need proportionately more milliliters of fluid per percent of burn than those with smaller burns. Also, patients with electrical injury, pulmonary injury, and delayed fluid resuscitation and those who were burned while intoxicated may need additional fluids. The following example illustrates use of the formula in a 70-kg (168-lb) patient with a 50% TBSA burn: 1. Consensus formula: 2 to 4 mL/kg/% TBSA 2. 2 × 70 × 50 = 7,000 mL/24 hours 3. Plan to administer: First 8 hours = 3,500 mL, or 437 mL/ hour; next 16 hours = 3,500 mL, or 219 mL/hour Most fluid replacement formulas use isotonic electrolyte solutions. Regardless of which standard replacement formula is used, the patient receives approximately the same fluid volume and sodium replacement during the first 48 hours. Another fluid replacement method requires hypertonic electrolyte solutions. This method uses concentrated solutions of sodium chloride and lactate (a balanced salt solution) so that the resulting fluid has a concentration of 250 to 300 mEq of sodium. The rationale for this replacement method is that by increasing serum osmolality, fluid will be pulled back into the vascular space from the interstitial space. Reduced systemic and pulmonary edema has been reported after administering hypertonic solutions.
!
NURSING ALERT Formulas are only a guide. The patient’s response, evidenced by heart rate, blood pressure, and urine output, is the primary determinant of actual fluid therapy and must be assessed at least hourly. Patient outcomes are improved by optimal fluid resuscitation.
Gerontologic Considerations Decreased function of the cardiovascular, renal, and pulmonary systems increases the need for close observation of elderly patients with even relatively minor burns during the emergent and acute phases. Acute renal failure is much more common in elderly patients than in those younger than age 40. The margin of difference between hypovolemia and fluid overload is very small. Suppressed immunologic response, a high incidence of malnutrition, and an inability to withstand metabolic stressors (eg, a cold environment) further compromise the elderly person’s ability to heal. As a result of these issues in elderly patients who sustain burn injury, close monitoring and prompt treatment of complications are mandatory.
Nursing Management: Emergent/Resuscitative Phase Assessment data obtained by prehospital providers (rescuers such as emergency medical technicians) are shared with the physician and nurse in the emergency department. Nursing assessment in the emergent phase of burn injury focuses on the major priorities for any trauma patient; the burn wound is a secondary consider-
ation. Aseptic management of the burn wounds and invasive lines continues. The nurse monitors vital signs frequently. Respiratory status is monitored closely, and apical, carotid, and femoral pulses are evaluated. Cardiac monitoring is indicated if the patient has a history of cardiac disease, electrical injury, or respiratory problems, or if the pulse is dysrhythmic or the rate is abnormally slow or rapid. If all extremities are burned, determining blood pressure may be difficult. A sterile dressing applied under the blood pressure cuff will protect the wound from contamination. Because increasing edema makes blood pressure difficult to auscultate, a Doppler (ultrasound) device or a noninvasive electronic blood pressure device may be helpful. In severe burns, an arterial catheter is used for blood pressure measurement and for collecting blood specimens. Peripheral pulses of burned extremities are checked hourly; the Doppler device is useful for this. Elevation of burned extremities is crucial to decrease edema. Elevation of the lower extremities on pillows and of the upper extremities on pillows or by suspension using intravenous poles may be helpful. Large-bore intravenous catheters and an indwelling urinary catheter are inserted, and the nurse’s assessment includes monitoring fluid intake and output. Urine output, an indicator of renal perfusion, is monitored carefully and measured hourly. The amount of urine first obtained when the urinary catheter was inserted is recorded. This may assist in determining the extent of preburn renal function and fluid status. Urine specific gravity, pH, and glucose, acetone, protein, and hemoglobin levels are assessed frequently. Burgundy-colored urine suggests the presence of hemochromogen and myoglobin resulting from muscle damage. This is associated with deep burns caused by electrical injury or prolonged contact with flames. Glucosuria, a common finding in the early postburn hours, results from the release of stored glucose from the liver in response to stress. Although not responsible for calculating the patient’s fluid requirements, the nurse needs to know the maximum volume of fluid the patient should receive. Infusion pumps and rate controllers are used to deliver a complex regimen of prescribed intravenous fluids. Administering and monitoring intravenous therapy are major nursing responsibilities. Body temperature, body weight, preburn weight, and history of allergies, tetanus immunization, past medical and surgical problems, current illnesses, and use of medications are assessed. A headto-toe assessment is performed, focusing on signs and symptoms of concomitant illness, injury, or developing complications. Patients with facial burns should have their eyes examined for potential injury to the corneas. An ophthalmologist is consulted for complete assessment via fluorescent staining. Assessing the extent of the burn wound continues and is facilitated with anatomic diagrams (described previously). In addition, the nurse works with the physician to assess the depth of the wound and areas of full- and partial-thickness injury. Assessment of the circumstances surrounding the injury is important. Obtaining a history of the burn injury can help to plan the care for the patient. Assessment should include the time of injury, mechanism of burn, whether the burn occurred in a closed space, the possibility of inhalation of noxious chemicals, and any related trauma. The neurologic assessment focuses on the patient’s level of consciousness, psychological status, pain and anxiety levels, and behavior. The patient’s and family’s understanding of the injury and treatment is assessed as well. Nursing care of the patient during the emergent/resuscitative phase of burn injury is detailed in the Plan of Nursing Care. (text continues on page 1718)
Chapter 57
Management of Patients With Burn Injury
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Plan of Nursing Care Care of the Patient During the Emergent/Resuscitative Phase of Burn Injury Nursing Interventions
Rationale
Expected Outcomes
Nursing Diagnosis: Impaired gas exchange related to carbon monoxide poisoning, smoke inhalation, and upper airway obstruction Goal: Maintenance of adequate tissue oxygenation 1. Provide humidified oxygen. 2. Assess breath sounds, and respiratory rate, rhythm, depth, and symmetry. Monitor patient for signs of hypoxia. 3. Observe for the following: a. Erythema or blistering of lips or buccal mucosa b. Singed nostrils c. Burns of face, neck, or chest d. Increasing hoarseness e. Soot in sputum or tracheal tissue in respiratory secretions 4. Monitor arterial blood gas values, pulse oximetry readings, and carboxyhemoglobin levels. 5. Report labored respirations, decreased depth of respirations, or signs of hypoxia to physician immediately. 6. Prepare to assist with intubation and escharotomies. 7. Monitor mechanically ventilated patient closely.
1. Humidified oxygen provides moisture to injured tissues; supplemental oxygen increases alveolar oxygenation. 2. These factors provide baseline data for further assessment and evidence of increasing respiratory compromise. 3. These signs indicate possible inhalation injury and risk of respiratory dysfunction.
• Absence of dyspnea • Respiratory rate between 12 and 20 breaths/min
• Lungs clear on auscultation • Arterial oxygen saturation >96% by pulse oximetry
• Arterial blood gas levels within normal limits
4. Increasing PCO2 and decreasing PO2 and O2 saturation may indicate need for mechanical ventilation. 5. Immediate intervention is indicated for respiratory difficulty. 6. Intubation allows mechanical ventilation. Escharotomy enables chest excursion in circumferential chest burns. 7. Monitoring allows early detection of decreasing respiratory status or complications of mechanical ventilation.
Nursing Diagnosis: Ineffective airway clearance related to edema and effects of smoke inhalation Goal: Maintain patent airway and adequate airway clearance 1. Maintain patent airway through proper patient positioning, removal of secretions, and artificial airway if needed. 2. Provide humidified oxygen. 3. Encourage patient to turn, cough, and deep breathe. Encourage patient to use incentive spirometry. Suction as needed.
1. A patent airway is crucial to respiration.
• Patent airway • Respiratory secretions are minimal, color-
2. Humidity liquefies secretions and facilitates expectoration. 3. These activities promote mobilization and removal of secretions.
• Respiratory rate, pattern, and breath
less, and thin
sounds normal
Nursing Diagnosis: Fluid volume deficit related to increased capillary permeability and evaporative losses from the burn wound Goal: Restoration of optimal fluid and electrolyte balance and perfusion of vital organs 1. Observe vital signs (including central venous pressure or pulmonary artery pressure, if indicated) and urine output, and be alert for signs of hypovolemia or fluid overload. 2. Monitor urine output at least hourly and weigh patient daily.
1. Hypovolemia is a major risk immediately after the burn injury. Overresuscitation might cause fluid overload. 2. Output and weight provide information about renal perfusion, adequacy of fluid replacement, and fluid requirement and fluid status.
• • • • • •
Serum electrolytes within normal limits Urine output between 0.5 and 1.0 mL/kg/hr Blood pressure higher than 90/60 mm Hg Heart rate less than 120 beats/min Exhibits clear sensorium Voids clear yellow urine with specific gravity within normal limits (continued)
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Unit 12
INTEGUMENTARY FUNCTION
Plan of Nursing Care Care of the Patient During the Emergent/Resuscitative Phase of Burn Injury (Continued) Nursing Interventions
Rationale
3. Maintain IV lines and regulate fluids at appropriate rates, as prescribed.
3. Adequate fluids are necessary to maintain fluid and electrolyte balance and perfusion of vital organs. 4. Rapid shifts in fluid and electrolyte status are possible in the postburn period.
4. Observe for symptoms of deficiency or excess of serum sodium, potassium, calcium, phosphorus, and bicarbonate. 5. Elevate head of patient’s bed and elevate burned extremities. 6. Notify physician immediately of decreased urine output, blood pressure, central venous, pulmonary artery, or pulmonary artery wedge pressures, or increased pulse rate.
Expected Outcomes
5. Elevation promotes venous return. 6. Because of the rapid fluid shifts in burn shock, fluid deficit must be detected early so that distributive shock does not occur.
Nursing Diagnosis: Hypothermia related to loss of skin microcirculation and open wounds Goal: Maintenance of adequate body temperature 1. Provide a warm environment through use of heat shield, space blanket, heat lights, or blankets. 2. Work quickly when wounds must be exposed. 3. Assess core body temperature frequently.
1. A stable environment minimizes evaporative heat loss. 2. Minimal exposure minimizes heat loss from wound. 3. Frequent temperature assessments help detect developing hypothermia.
• Body temperature remains 36.1° to 38.3°C (97° to 101°F)
• Absence of chills or shivering
Nursing Diagnosis: Pain related to tissue and nerve injury and emotional impact of injury Goal: Control of pain 1. Use pain intensity scale to assess pain level (ie, 1 to 10). Differentiate from hypoxia. 2. Administer intravenous opioid analgesics as prescribed. Observe for respiratory depression in the patient who is not mechanically ventilated. Assess response to analgesic. 3. Provide emotional support and reassurance.
1. Pain level provides baseline for evaluating effectiveness of pain relief measures. Hypoxia can cause similar signs and must be ruled out before analgesic medication is administered. 2. Intravenous administration is necessary because of altered tissue perfusion from burn injury.
• States pain level is decreased • Absence of nonverbal cues of pain
3. Emotional support is essential to reduce fear and anxiety resulting from burn injury. Fear and anxiety increase the perception of pain.
Nursing Diagnosis: Anxiety related to fear and the emotional impact of burn injury Goal: Minimization of patient’s and family’s anxiety 1. Assess patient’s and family’s understanding of burn injury, coping skills, and family dynamics. 2. Individualize responses to the patient’s and family’s coping level. 3. Explain all procedures to the patient and the family in clear, simple terms.
1. Previous successful coping strategies can be fostered for use in the present crisis. Assessment allows planning of individualized interventions. 2. Reactions to burn injury are extremely variable. Interventions must be appropriate to the patient’s and family’s present level of coping. 3. Increased understanding alleviates fear of the unknown. High levels of anxiety may interfere with understanding of complex explanations.
• Patient and family verbalize understanding of emergent burn care
• Able to answer simple questions
(continued)
Chapter 57
Management of Patients With Burn Injury
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Plan of Nursing Care Care of the Patient During the Emergent/Resuscitative Phase of Burn Injury (Continued) Nursing Interventions
Rationale
4. Maintain adequate pain relief. 5. Consider administering prescribed antianxiety medications if the patient remains extremely anxious despite nonpharmacologic interventions.
4. Pain increases anxiety. 5. Anxiety levels during the emergent phase may exceed the patient’s coping abilities. Medication decreases physiologic and psychological anxiety responses.
Expected Outcomes
Collaborative Problems: Acute respiratory failure, distributive shock, acute renal failure, compartment syndrome, paralytic ileus, Curling’s ulcer Goal: Absence of complications Acute Respiratory Failure 1. Assess for increasing dyspnea, stridor, changes in respiratory patterns. 2. Monitor pulse oximetry, arterial blood gas values for decreasing PO2 and oxygen saturation, and increasing PCO2. 3. Monitor chest x-ray results. 4. Assess for restlessness, confusion, difficulty attending to questions, or decreasing level of consciousness. 5. Report deteriorating respiratory status immediately to physician. 6. Prepare to assist with intubation or escharotomies as indicated. Distributive Shock 1. Assess for decreasing urine output, pulmonary artery and pulmonary artery wedge pressures, blood pressure, and cardiac output, or increasing pulse. 2. Assess for progressive edema as fluid shifts occur. 3. Adjust fluid resuscitation in collaboration with the physician in response to physiologic findings. Acute Renal Failure 1. Monitor urine output and blood urea nitrogen (BUN) and creatinine levels. 2. Report decreased urine output or increased BUN and creatinine values to physician. 3. Assess urine for hemoglobin or myoglobin. 4. Administer increased fluids as prescribed.
Compartment Syndrome 1. Assess peripheral pulses hourly with Doppler ultrasound device. 2. Assess warmth, capillary refill, sensation, and movement of extremity hourly. Compare affected with unaffected extremity.
1. Such signs reflect deteriorating respiratory status. 2. Such signs reflect decreased oxygenation status. 3. X-ray may disclose pulmonary injury. 4. Such manifestations may indicate cerebral hypoxia.
• Arterial blood gas values within acceptable limits: PO2 >80 mm Hg, PCO2 90/60 mm Hg)
• Heart rate within patient’s normal range (usually 21 mm Hg. May have fluctuating (COAG) If medical treatment is unsuccessful, laser IOPs. Usually no symptoms but possible trabeculoplasty (LT) can provide a 20% ocular pain, headache, and halos. drop in intraocular pressure. Glaucoma filtering surgery if continued optic nerve damage despite medication therapy and LT. Treatment similar to COAG, however, the IOP ≤ 21 mm Hg. Optic nerve damage, Normal tension glaucoma best management for normal tension glauvisual field defects. coma management is yet to be established. Goal is to lower the IOP by at least 30%. Lower IOP by at least 20%. Elevated IOP. Possible ocular pain or Ocular hypertension headache. Angle-Closure (Pupillary Block) Glaucomas Obstruction in aqueous humor outflow due to the complete or partial closure of the angle from the forward shift of the peripheral iris to the trabecula. The obstruction results in an increased IOP. Acute angle-closure glaucoma Ocular emergency; administration of hyperRapidly progressive visual impairment, peri(AACG) osmotics, azetazolamide, and topical ocular ocular pain, conjunctival hyperemia, and hypotensive agents, such as pilocarpine and congestion. Pain may be associated with beta-blockers (betaxolol). Possible laser nausea, vomiting, bradycardia, and profuse incision in the iris (iridotomy) to release sweating. Reduced central visual acuity, blocked aqueous and reduce IOP. Other severely elevated IOP, corneal edema. eye is also treated with pilocarpine eye Pupil is vertically oval, fixed in a semidrops and/or surgical management to dilated position, and unreactive to light avoid a similar spontaneous attack. and accommodation. Subacute angle-closure glaucoma Prophylactic peripheral laser iridotomy. Transient blurring of vision, halos around Can lead to acute or chronic angle-closure lights; temporal headaches and/or ocular glaucoma if untreated. pain; pupil may be semi-dilated. Chronic angle-closure glaucoma Management similar to that for COAG: Progression of glaucomatous cupping and includes laser iridotomy and medications. significant visual field loss; IOP may be normal or elevated; ocular pain and headache. IOP, intraocular pressure.
Chapter 58
Assessment and Management of Patients With Eye and Vision Disorders
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Assessment and Diagnostic Findings
Medical Management
The purpose of a glaucoma workup is to establish the diagnostic category, assess the optic nerve damage, and formulate a treatment plan. The patient’s ocular and medical history must be detailed to investigate the history of predisposing factors. There are four major types of examinations used in glaucoma evaluation, diagnosis, and management: tonometry to measure the IOP, ophthalmoscopy to inspect the optic nerve, gonioscopy to examine the filtration angle of the anterior chamber, and perimetry to assess the visual fields. The changes in the optic nerve significant for the diagnosis of glaucoma are pallor and cupping of the optic nerve disc. The pallor of the optic nerve is caused by a lack of blood supply that results from cellular destruction. Cupping is characterized by exaggerated bending of the blood vessels as they cross the optic disc, resulting in an enlarged optic cup that appears more basinlike compared with a normal cup. The progression of cupping in glaucoma is caused by the gradual loss of retinal nerve fibers accompanied by the loss of blood supply, resulting in increased pallor of the optic disc. As the optic nerve damage increases, visual perception in the area is lost. The localized areas of visual loss (ie, scotomas) represent loss of retinal sensitivity and are measured and mapped by perimetry. The results are mapped on a graph. In patients with glaucoma, the graph has a distinct pattern that is different from other ocular diseases and is useful in establishing the diagnosis. Figure 58-8 shows the progression of visual field defects caused by glaucoma.
The aim of all glaucoma treatment is prevention of optic nerve damage through medical therapy, laser or nonlaser surgery, or a combination of these approaches. Lifelong therapy is almost always necessary because glaucoma cannot be cured. Although treatment cannot reverse optic nerve damage, further damage can be controlled. The treatment goal is to maintain an IOP within a range unlikely to cause further damage. The initial target for IOP among patients with elevated IOP and those with low-tension glaucoma with progressive visual field loss is typically set at 30% lower than the current pressure. The patient is monitored for the stability of the optic nerve. If there is evidence of progressive damage, the target IOP is again lowered until the optic nerve shows stability. Treatment focuses on achieving the greatest benefit at the least risk, cost, and inconvenience to the patient. All treatment options have potential complications, especially surgery, which yields the best success rates. In the United States, medical management is the common approach, and surgical management is the last resort. In Great Britain, the initial treatment of choice is surgery (Fechtner & Singh, 2001).
A
B
C
D
E
F
FIGURE 58-8 Progression of glaucomatous visual field defects. A central scotoma at 10 to 20 degrees of fixation near the blind spot is the initial significant finding (A, B). As the glaucoma progresses, the scotomas enlarge and deepen, resulting in peripheral vision loss. (C) Defect within 5 degrees of fixation point nasally. (D) Peripheral involvement enlarges. (E) Ringlike scotoma. (F) Eventually, vision is lost. The resulting “island of vision” becomes the characteristic visual field appearance of glaucoma and correlates with the “tunnel vision,” in which peripheral vision is lost. From Kanski, J. J. (1999). Clinical ophthalmology. Oxford: Butterworth-Heinemann Ltd.
PHARMACOLOGIC THERAPY Medical management of glaucoma relies on systemic and topical ocular medications that lower IOP. Periodic follow-up examinations are essential to monitor IOP, appearance of the optic nerve, visual fields, and side effects of medications. In considering a therapeutic regimen, the ophthalmologist aims for the greatest effectiveness with the least side effects, inconvenience, and cost. Therapy takes into account the patient’s health and stage of glaucoma. Comfort, affordability, convenience, lifestyle, and personality are factors to consider in the patient’s compliance with the medical regimen. The patient is usually started on the lowest dose of topical medication and then advanced to increased concentrations until the desired IOP level is reached and maintained. Because of their efficacy, minimal dosing (can be used once each day), and low cost, beta-blockers are the preferred initial topical medications. One eye is treated first, with the other eye used as a control in determining the efficacy of the medication; once efficacy has been established, treatment of the fellow eye is started. If the IOP is elevated in both eyes, both are treated. When results are not satisfactory, a new medication is substituted. The main markers of the efficacy of the medication in glaucoma control are lowering of the IOP to the target pressure, appearance of the optic nerve head, and the visual field. Several types of ocular medications are used to treat glaucoma (Table 58-5), including miotics (ie, cause pupillary constriction), adrenergic agonists (ie, sympathomimetic agents), beta-blockers, alpha2-agonists (ie, adrenergic agents), carbonic anhydrase inhibitors, and prostaglandins. Cholinergics (ie, miotics) increase the outflow of the aqueous humor by affecting ciliary muscle contraction and pupil constriction, allowing flow through a larger opening between the iris and the trabecular meshwork. Adrenergic agonists increase aqueous outflow but primarily decrease aqueous production with an action similar to beta-blockers and carbonic anhydrase inhibitors. SURGICAL MANAGEMENT In laser trabeculoplasty for glaucoma, laser burns are applied to the inner surface of the trabecular meshwork to open the intratrabecular spaces and widen the canal of Schlemm, thereby pro-
Unit 13
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Table 58-5
SENSORINEURAL FUNCTION
• Medications Used in the Management of Glaucoma
MEDICATION
ACTION
SIDE EFFECTS
NURSING IMPLICATIONS
Cholinergics (miotics) (pilocarpine, carbachol)
Periorbital pain, blurry vision, difficulty seeing in the dark
Caution patients about diminished vision in dimly lit areas
Adrenergic agonists (dipivefrin, epinephrine)
Increases aqueous fluid outflow by contracting the ciliary muscle and causing miosis (constriction of the pupil) and opening of trabecular meshwork Reduces production of aqueous humor and increases outflow
Teach patients punctal occlusion to limit systemic effects (described in Chart 58–10.)
Beta-blockers (betaxolol, timolol)
Decreases aqueous humor production
Eye redness and burning; can have systemic effects, including palpitations, elevated blood pressure, tremor, headaches, and anxiety Can have systemic effects, including bradycardia, exacerbation of pulmonary disease, and hypotension
Alpha-adrenergic agonists (apraclonidine, brimonidine) Carbonic anhydrase inhibitors (acetazolamide, methazolamide, dorzolamide)
Decreases aqueous humor production
Eye redness, dry mouth and nasal passages
Decreases aqueous humor production
Prostaglandin analogs (latanoprost)
Increases uveoscleral outflow
Oral medications (acetazolamide and methazolamide) associated with serious side effects, including anaphylactic reactions, electrolyte loss, depression, lethargy, gastrointestinal upset, impotence, and weight loss; topical form (dorzolamide) side effects include topical allergy Darkening of the iris, conjunctival redness, possible rash
moting outflow of aqueous humor and decreasing IOP. The procedure is indicated when IOP is inadequately controlled by medications; it is contraindicated when the trabecular meshwork cannot be fully visualized because of narrow angles. A serious complication of this procedure is a transient rise in IOP (usually 2 hours after surgery) that may become persistent. IOP assessment in the immediate postoperative period is essential. In laser iridotomy for pupillary block glaucoma, an opening is made in the iris to eliminate the pupillary block. Laser iridotomy is contraindicated in patients with corneal edema, which interferes with laser targeting and strength. Potential complications are burns to the cornea, lens, or retina; transient elevated IOP; closure of the iridotomy; uveitis; and blurring. Pilocarpine is usually prescribed to prevent closure of the iridotomy. Filtering procedures for chronic glaucoma are used to create an opening or fistula in the trabecular meshwork to drain aqueous humor from the anterior chamber to the subconjunctival space into a bleb, thereby bypassing the usual drainage structures. This allows the aqueous humor to flow and exit by different routes (ie, absorption by the conjunctival vessels or mixing with tears). Trabeculectomy is the standard filtering technique used to remove part of the trabecular meshwork. Complications include hemorrhage, an extremely low (hypotony) or elevated IOP, uveitis, cataracts, bleb failure, bleb leak, and endophthalmitis. Unlike other surgical procedures, the filtering procedure’s goal in glau-
Contraindicated in patients with asthma, chronic obstructive pulmonary disease, second- or third-degree heart block, bradycardia, or cardiac failure; teach patients punctal occlusion to limit systemic effects Teach patients punctal occlusion to limit systemic effects Do not administer to patients with sulfa allergies; monitor electrolyte levels
Instruct patients to report any side effects
coma treatment is to achieve incomplete healing of the surgical wound. The outflow of aqueous humor in a newly created drainage fistula is circumvented by the granulation of fibrovascular tissue or scar tissue formation on the surgical site. Scarring is inhibited by using antifibrosis agents such as the antimetabolites fluorouracil (Efudex) and mitomycin (Mutamycin). Like all antineoplastic agents, they require special handling procedures before, during, and after the procedure. Fluorouracil can be administered intraoperatively and by subconjunctival injection during followup; mitomycin is much more potent and is administered only intraoperatively. Drainage implants or shunts are open tubes implanted in the anterior chamber to shunt aqueous humor to an attached plate in the conjunctival space. A fibrous capsule develops around the episcleral plate and filters the aqueous humor, thereby regulating the outflow and controlling IOP.
Nursing Management TEACHING PATIENTS ABOUT GLAUCOMA CARE The medical and surgical management of glaucoma slows the progression of glaucoma but does not cure it. The lifelong therapeutic regimen mandates patient education. The nature of the disease and the importance of strict adherence to the medication regimen must be explained to help ensure compliance. A thor-
Chapter 58
Assessment and Management of Patients With Eye and Vision Disorders
ough patient interview is essential to determine systemic conditions, current systemic and ocular medications, family history, and problems with compliance to glaucoma medications. Then the medication program can be discussed, particularly the interactions of glaucoma-control medications with other medications. For example, the diuretic effect of acetazolamide has an additive effect on the diuretic effects of other antihypertensive medications and can result in hypokalemia. The effects of glaucomacontrol medications on vision must also be explained. Miotics and sympathomimetics result in altered focus; therefore, patients need to be cautious in navigating their surroundings. Information about instilling ocular medication and preventing systemic absorption with punctal occlusion is described in the section on ophthalmic medications. Nurses in all settings encounter patients with glaucoma. Even patients with long-standing disease and those with glaucoma as a secondary diagnosis should be assessed for knowledge level and compliance with the therapeutic regimen. Chart 58-4 contains points to review with glaucoma patients. CONTINUING GLAUCOMA CARE AT HOME For patients with severe glaucoma and impaired function, referral to services that assist the patient in performing customary activities may be needed. The loss of peripheral vision impairs mobility the most. These patients need to be referred to lowvision and rehabilitation services. Patients who meet the criteria for legal blindness should be offered referrals to agencies that assist in obtaining federal assistance. Reassurance and emotional support are important aspects of care. A lifelong disease involving a possible loss of sight has psychological, physical, social, and vocational ramifications. The
Chart 58-4
• PATIENT EDUCATION Managing Glaucoma • Know your intraocular pressure (IOP) measurement and the desired range.
• Be informed about the extent of your vision loss and optic nerve damage.
• Keep a record of your eye pressure measurements and visual field test results to monitor your own progress.
• Review all your medications (including over-the-counter and • • • • • • • •
herbal medications) with your ophthalmologist, and mention any side effects each time you visit. Ask about potential side effects and drug interactions of your eye medications. Ask whether generic or less costly forms of your eye medications are available. Review the dosing schedule with your ophthalmologist and inform him or her if you have trouble complying with the schedule. Participate in the decision-making process. Let your doctor know what dosing schedule works for you and other preferences regarding your eye care. Have the nurse observe you instilling eye medication to determine whether you are administering it properly. Be aware that glaucoma medications can cause adverse effects if used inappropriately. Eyedrops are to be administered as prescribed, not when eyes feel irritated. Ask your ophthalmologist to send a report to your primary care physician after each appointment. Keep all follow-up appointments.
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family must be integrated into the plan of care, and because the disease has a familial tendency, family members should be encouraged to undergo examinations at least once every 2 years to detect glaucoma early.
Cataracts A cataract is a lens opacity or cloudiness (Fig. 58-9). Cataracts rank only behind arthritis and heart disease as a leading cause of disability in older adults. Cataracts affect nearly 20.5 million Americans who are 40 years of age or older, or about one in every six people in this age range. By age 80, more than half of all Americans have cataracts. According to the World Health Organization, cataract is the leading cause of blindness in the world (Preshel & Prevent Blindness America, 2002).
Pathophysiology Cataracts can develop in one or both eyes at any age for a variety of causes (Chart 58-5). Visual impairment normally progresses at the same rate in both eyes over many years or in a matter of months. The three most common types of senile (age-related) cataracts are defined by their location in the lens: nuclear, cortical, and posterior subcapsular. The extent of visual impairment depends on the size, density, and location in the lens. More than one type can be present in one eye. A nuclear cataract is associated with myopia (ie, nearsightedness), which worsens when the cataract progresses. If dense, the cataract severely blurs vision. Periodic changes in prescription eyeglasses help manage this problem. A cortical cataract involves the anterior, posterior, or equatorial cortex of the lens. A cataract in the equator or periphery of the cortex does not interfere with the passage of light through the center of the lens and has little effect on vision. Cortical cataracts progress at a highly variable rate. Vision is worse in very bright light. Studies show that people with the highest levels of sunlight exposure have twice the risk of developing cortical cataracts than those with low-level sunlight exposure (West et al., 1998). Posterior subcapsular cataracts occur in front of the posterior capsule. This type typically develops in younger people and, in some cases, is associated with prolonged corticosteroid use, inflammation, or trauma. Near vision is diminished, and the eye is increasingly sensitive to glare from bright light (eg, sunlight, headlights).
FIGURE 58-9 A cataract is a cloudy or opaque lens. On visual inspection, the lens appears grey or milky. From Rubin, E., & Farber, J. L. (1999). Pathology (3rd ed.). Philadelphia: Lippincott Williams & Wilkins.
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Unit 13
SENSORINEURAL FUNCTION
Chart 58-5
Risk Factors for Cataract Formation Aging • Loss of lens transparency • Clumping or aggregation of lens protein (which leads to light scattering) • Accumulation of a yellow-brown pigment due to the breakdown of lens protein • Decreased oxygen uptake • Increase in sodium and calcium • Decrease in levels of vitamin C, protein, and glutathione (an antioxidant) Associated Ocular Conditions • Retinitis pigmentosa • Myopia • Retinal detachment and retinal surgery • Infection (eg, herpes zoster, uveitis) Toxic Factors • Corticosteroids, especially at high doses and in long-term use • Alkaline chemical eye burns, poisoning • Cigarette smoking • Calcium, copper, iron, gold, silver, and mercury, which tend to deposit in the pupillary area of the lens Nutritional Factors • Reduced levels of antioxidants • Poor nutrition • Obesity Physical Factors • Dehydration associated with chronic diarrhea, use of purgatives in anorexia nervosa, and use of hyperbaric oxygenation • Blunt trauma, perforation of the lens with a sharp object or foreign body, electric shock • Ultraviolet radiation in sunlight and x-ray Systemic Diseases and Syndromes • Diabetes mellitus • Down syndrome • Disorders related to lipid metabolism • Renal disorders • Musculoskeletal disorders
Clinical Manifestations Painless, blurry vision is characteristic of cataracts. The patient perceives that surroundings are dimmer, as if glasses need cleaning. Light scattering is common, and the individual experiences reduced contrast sensitivity, sensitivity to glare, and reduced visual acuity. Other effects include myopic shift, astigmatism, monocular diplopia (ie, double vision), color shift (ie, the aging lens becomes progressively more absorbent at the blue end of the spectrum), brunescens (ie, color values shift to yellow-brown), and reduced light transmission.
Assessment and Diagnostic Findings Decreased visual acuity is directly proportionate to cataract density. The Snellen visual acuity test, ophthalmoscopy, and slitlamp biomicroscopic examination are used to establish the degree of cataract formation. The degree of lens opacity does not always correlate with the patient’s functional status. Some patients can perform normal activities despite clinically significant cataracts. Others with less lens opacification have a disproportionate de-
crease in visual acuity; hence, visual acuity is an imperfect measure of visual impairment.
Medical Management No nonsurgical treatment cures cataracts. Ongoing studies are investigating ways to slow cataract progression, such as intake of antioxidants (eg, vitamin C, beta-carotene, vitamin E) (Age-Related Eye Disease Research Study Group, 2001). In the early stages of cataract development, glasses, contact lenses, strong bifocals, or magnifying lenses may improve vision. Reducing glare with proper light and appropriate lighting can facilitate reading. Mydriatics can be used as short-term treatment to dilate the pupil and allow more light to reach the retina, although this increases glare. SURGICAL MANAGEMENT Fewer than 15% of people with cataracts suffer vision problems severe enough to require surgery. In general, if reduced vision from cataract does not interfere with normal activities, surgery may not be needed. However, in deciding when cataract surgery is to be performed, the patient’s functional and visual status should be a primary consideration. Surgery is performed on an outpatient basis and usually takes less than 1 hour, with the patient being discharged in 30 minutes or less afterward. Although complications from cataract surgery are uncommon, they can have significant effects on vision (Table 58-6). Restoration of visual function through a safe and minimally invasive procedure is the surgical goal, which is achieved with advances in topical anesthesia, smaller wound incision (ie, clear cornea incision), and lens design (ie, foldable and more accurate intraocular lens measurements). Topical anesthesia, such as lidocaine gel applied to the surface of the eye, eliminates the hazards of regional anesthesia, such as ocular perforation, retrobulbar hemorrhage, optic injuries, diplopia, and ptosis, and is ideal for patients receiving anticoagulants. Moreover, patients can communicate and cooperate during surgery. When both eyes have cataracts, one eye is treated first, with at least several weeks, preferably months, separating the two operations. Because cataract surgery is performed to improve visual functioning, the delay for the other eye gives time for the patient and the surgeon to evaluate whether the results from the first surgery are adequate enough to preclude the need for a second operation. The delay also provides time for the first eye to recover; if there are any complications, the surgeon may decide to perform the second procedure differently. Intracapsular Cataract Extraction. From the late 1800s until the 1970s, the technique of choice for cataract extraction was intracapsular cataract extraction (ICCE). The entire lens (ie, nucleus, cortex, and capsule) is removed, and fine sutures close the incision. ICCE is infrequently performed today; however, it is indicated when there is a need to remove the entire lens, such as with a subluxated cataract (ie, partially or completely dislocated lens). Extracapsular Surgery. Extracapsular cataract extraction (ECCE) achieves the intactness of smaller incisional wounds (less trauma to the eye) and maintenance of the posterior capsule of the lens, reducing postoperative complications, particularly aphakic retinal detachment and cystoid macular edema. In ECCE, a portion of the anterior capsule is removed, allowing extraction of the lens nucleus and cortex. The posterior capsule and zonular support are left intact. An intact zonular-capsular diaphragm provides the needed safe anchor for the posterior chamber intraocular lens (IOL). After the pupil has been dilated and the surgeon has made
Chapter 58
Table 58-6
Assessment and Management of Patients With Eye and Vision Disorders
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• Potential Complications of Cataract Surgery
COMPLICATION
EFFECTS
MANAGEMENT AND OUTCOME
Immediate Preoperative Retrobulbar hemorrhage: can result from retrobulbar infiltration of anesthetic agents if the short ciliary artery is located by the injectia
Increased IOP, proptosis, lid tightness, and subconjunctival hemorrhage with or without edema
Emergent lateral canthotomy (slitting of the canthus) is performed to stop central retinal perfusion when the IOP is dangerously elevated. If this procedure fails to reduce IOP, a puncture of the anterior chamber with removal of fluid is considered. The patient must be closely monitored for at least a few hours. Postponement of cataract surgery for 2 to 4 weeks is advised. Complications such as iris prolapse, vitreous loss, and choroidal hemorrhage could result in a catastrophic visual outcome.
Intraoperative Complications Rupture of the posterior capsule Suprachoroidal (expulsive) hemorrhage: profuse bleeding into the suprachoroidal space
May result in loss of vitreous Extrusion of intraocular contents from the eye or opposition of retinal surfaces
Anterior vitrectomy is required if vitreous loss occurs. Closure of the incision and administration of a hyperosmotic agent to reduce IOP or corticosteroids to reduce intraocular inflammation. Vitrectomy is performed 1 to 2 weeks later. Visual prognosis is poor; some useful vision may be salvaged on rare occasions.
Characterized by marked visual loss, pain, lid edema, hypopyon, corneal haze, and chemosis
Managed by aggressive antibiotic therapy. Broadspectrum antibiotics are administered while awaiting culture and sensitivity results. Once results are obtained, the appropriate antibiotics are administered via intravitreal injection. Corticosteroid therapy is also administered.
Toxic reactions or mechanical injury from broken or loose sutures
Suture removal relieves the symptoms. Topical corticosteroids are used when the incision is not healed and sutures cannot be removed. Miotics are used for mild cases, whereas IOL removal and replacement is necessary for severe cases. Corticosteroids and antibiotics are administered systemically. If the condition persists, removal of the IOL and capsular bag, vitrectomy, and intravitreal injection of antibiotics are required. YAG laser is used to create a hole in the posterior capsule. Blurred vision is cleared immediately.
Early Postoperative Complications Acute bacterial endophthalmitis: devastating complication that occurs in about 1 in 1000 cases; the most common causative organisms are Staphylococcus epidermitus, S. aureus, Pseudomonas and Proteus species Late Postoperative Complications Suture-related problems Malposition of the IOL Chronic endophthalmitis
Opacification of the posterior capsule (most common late complication of extracapsular cataract extraction)
Results in astigmatism, sensitivity to glare, or appearance of halos Persistent, low-grade inflammation and granuloma Visual acuity is diminished.
IOP, intraocular pressure.
a small incision on the upper edge of the cornea, a viscoelastic substance (clear gel) is injected into the space between the cornea and the lens. This prevents the space from collapsing and facilitates insertion of the IOL. Phacoemulsification. This method of extracapsular surgery uses an ultrasonic device that liquefies the nucleus and cortex, which are then suctioned out through a tube. The posterior capsule is left intact. Because the incision is even smaller than the standard ECCE, the wound heals more rapidly, and there is early stabilization of refractive error and less astigmatism. Hardware and software advances in ultrasonic technology—including new phaco needles that are used to cut and aspirate the cataract— permit safe and efficient removal of nearly all cataracts through a clear cornea incision that is as small or smaller than required for available foldable lenses. Ultimately, advances in technology will achieve an injectable IOL.
Lens Replacement. After removal of the crystalline lens, the patient is referred to as aphakic (ie, without lens). The lens, which focuses light on the retina, must be replaced for the patient to see clearly. There are three lens replacement options: aphakic eyeglasses, contact lenses, and IOL implants. Aphakic glasses are effective but heavy. Objects are magnified by 25%, making them appear closer than they actually are. Objects are magnified unequally, creating distortion. Peripheral vision is also limited, and binocular vision (ie, ability of both eyes to focus on one object and fuse the two images into one) is impossible if the other eye is phakic (normal). Contact lenses provide patients with almost normal vision, but because contact lenses need to be removed occasionally, the patient also needs a pair of aphakic glasses. Contact lenses are not advised for patients who have difficulty inserting, removing, and cleaning them. Frequent handling and improper disinfection increase the risk for infection.
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Insertion of IOLs during cataract surgery is the usual approach to lens replacement. After ICCE, the surgeon implants an anterior chamber IOL in front of the iris. Posterior chamber lenses, generally used in ECCE, are implanted behind the iris. ECCE and posterior chamber IOLs are associated with a relatively low incidence of complications (eg, hyphema, macular edema, secondary glaucoma, damage to the corneal endothelium). IOL implantation is contraindicated in patients with recurrent uveitis, proliferative diabetic retinopathy, neovascular glaucoma, or rubeosis iridis. Like any device, IOLs can malfunction and cause complications.
Nursing Management The patient with cataracts should receive the usual preoperative care for ambulatory surgical patients undergoing eye surgery. According to the study on Medical Testing for Cataract Surgery, routine preoperative testing before cataract surgery does not improve health or clinical outcomes. Hence, the standard battery of preoperative tests should be prescribed only when they would have been indicated by the patient’s medical history (Schein et al., 2000). PROVIDING PREOPERATIVE CARE To reduce the risk for retrobulbar hemorrhage (after retrobulbar injection), any anticoagulation therapy that the patient is receiving is withheld, if medically appropriate. Aspirin should be withheld for 5 to 7 days, nonsteroidal anti-inflammatory medications (NSAIDs) for 3 to 5 days, and warfarin (Coumadin) until the prothrombin time of 1.5 is almost reached. Dilating drops are administered every 10 minutes for four doses at least 1 hour before surgery. Additional dilating drops may be administered in the operating room (immediately before surgery) if the affected eye is not fully dilated. Antibiotic, corticosteroid, and NSAID drops may be administered prophylactically to prevent postoperative infection and inflammation. PROVIDING POSTOPERATIVE CARE After recovery from anesthesia, the patient receives verbal and written instruction regarding how to protect the eye, administer medications, recognize signs of complications, and obtain emergency care. Activities to be avoided are identified in Chart 58-6. The nurse also explains that there is minimal discomfort after surgery and in-
structs the patient to take a mild analgesic agent, such as acetaminophen, as needed. Antibiotic, anti-inflammatory, and corticosteroid eye drops or ointments are prescribed postoperatively. A clinical pathway for the care of patients undergoing ambulatory cataract surgery is presented in Appendix A at the end of the book. PROMOTING HOME AND COMMUNITY-BASED CARE Teaching Patients Self-Care. To prevent accidental rubbing or poking of the eye, the patient wears a protective eye patch for 24 hours after surgery, followed by eyeglasses worn during the day and a metal shield worn at night for 1 to 4 weeks. The nurse instructs the patient and family in applying and caring for the eye shield. Sunglasses should be worn while outdoors during the day because the eye is sensitive to light. Slight morning discharge, some redness, and a scratchy feeling may be expected for a few days. A clean, damp washcloth may be used to remove slight morning eye discharge. Because cataract surgery increases the risk for retinal detachment, the patient must know to notify the surgeon if new floaters (ie, dots) in vision, flashing lights, decrease in vision, pain, or increase in redness occurs. Continuing Care. The eye patch is removed after the first followup appointment. Patients may experience blurring of vision for several days to weeks. Sutures left in the eye alter the curvature of the cornea, resulting in temporary blurring and some astigmatism. Vision gradually improves as the eye heals. Patients with IOL implants have visual improvement faster than those waiting for aphakic glasses or contact lenses. Vision is stabilized when the eye is completely healed, usually within 6 to 12 weeks, when final corrective prescription is completed. Visual correction is needed for any remaining nearsightedness or farsightedness (even in patients with IOL implants).
Corneal Disorders CORNEAL DYSTROPHIES Corneal dystrophies are inherited as autosomal dominant traits and manifest when the person is about 20 years of age. They are characterized by deposits in the corneal layers. Decreased vision
Chart 58-6 Home Care Checklist • Intraocular Lens Implant At the completion of the home care instruction, the patient or caregiver will be able to: • Wear glasses or metal eye shield at all times following surgery as instructed by the physician. • Always wash hands before touching or cleaning the postoperative eye. • Clean postoperative eye with a clean tissue; wipe the closed eye with a single gesture from the inner canthus outward. • Bathe or shower; shampoo hair cautiously or seek assistance. • Avoid lying on the side of the affected eye the night after surgery. • Keep activity light (eg, walking, reading, watching television). Resume the following activities only as directed by the physician: driving, sexual activity, unusually strenuous activity. • Remember not to lift, push, or pull objects heavier than 15 lb. • Avoid bending or stooping for an extended period. • Be careful when climbing or descending stairs. • Know when to call the physician.* *Call the physician immediately if any of the following problems occur before the next physician’s appointment: (1) vision changes; (2) continuous flashing lights appear to the affected eye; (3) redness, swelling, or pain increase in the eye; (4) the amount or type of eye drainage changes; (5) the eye is injured in any way; (6) significant pain is not relieved by acetaminophen.
Patient
Caregiver
✓ ✓
✓
✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓
✓
✓
Chapter 58
Assessment and Management of Patients With Eye and Vision Disorders
is caused by the irregular corneal surface and corneal deposits. Corneal endothelial decompensation leads to corneal edema and blurring of vision. Persistent edema leads to bullous keratopathy, which is formation of blisters that cause pain and discomfort on rupturing. This condition is usually associated with primary openangle glaucoma. A bandage contact lens is used to flatten the bullae, protect the exposed corneal nerve endings, and relieve discomfort. Symptomatic treatments, such as hypertonic drops or ointment (5% sodium chloride), may reduce epithelial edema; lowering the IOP also reduces stromal edema. Penetrating keratoplasty has a high success rate in advanced cases (see “Corneal Surgeries”). For diffuse bullous keratopathy, amniotic membrane transplantation may become the procedure of choice for patients with limited visual potential (Rapuano, 2000).
KERATOCONUS Keratoconus is a condition characterized by a conical protuberance of the cornea with progressive thinning on protrusion and irregular astigmatism. The hereditary condition has a higher incidence among women. Onset occurs at puberty; the condition may progress for more than 20 years and is bilateral. Corneal scarring occurs in severe cases. Blurred vision is a prominent symptom. Rigid, gas-permeable contact lenses correct irregular astigmatism and improve vision. Advances in contact lens design have reduced the need for surgery. Penetrating keratoplasty is indicated when contact lens correction is no longer effective.
CORNEAL SURGERIES Among the surgical procedures used to treat diseased corneal tissue are phototherapeutic keratectomy (PTK) and keratoplasty.
Phototherapeutic Keratectomy PTK is a laser procedure that is used to treat diseased corneal tissue by removing or reducing corneal opacities and smoothing the anterior corneal surface to improve functional vision. PTK is a safer, more effective (when indicated) alternative than penetrating or lamellar keratoplasty. PTK is contraindicated in patients with active herpetic keratitis because the ultraviolet rays may reactivate latent virus. Common side effects are induced hyperopia and stromal haze. Complications are delayed re-epithelialization (particularly in patients with diabetes) and bacterial keratitis. Postoperative management consists of oral analgesics for eye pain. Re-epithelialization is promoted with a pressure patch or therapeutic soft contact lens. Antibiotic and corticosteroid ointment and NSAIDs are prescribed postoperatively. Follow-up examinations are required for up to 2 years.
Keratoplasty Keratoplasty (ie, corneal transplantation or corneal grafting) involves replacing abnormal host tissue with a healthy donor corneal tissue. Common indications are keratoconus, corneal dystrophy, corneal scarring from herpes simplex keratitis, and chemical burns. Several factors affect the success of the graft: ocular structures (eg, lids, conjunctiva), tear film function, adequacy of blinking, and viability of the donor endothelium. Tissue that is the possible source of disease transmission from donor to recipient or
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cornea with functionally compromised endothelium is typically not used for grafting (Chart 58-7), nor is corneal tissue used from donors who have undergone laser-assisted in situ keratomileusis (LASIK) because the cornea is no longer intact. Conditions such as glaucoma, retinal disease, and strabismus (ie, deviation in ocular alignment) can negatively influence the outcome. Promising experimental therapies include stem cell transplants (Rongé, 2001) and autologous limbal epithelial cell transplants (Tsai et al., 2000). The surgeon determines the graft size before the procedure, and the appropriate size is marked on the surface of the cornea. The surgeon prepares the donor cornea and the recipient bed, removes the diseased cornea, places the donor cornea on the recipient bed, and sutures it in place. Sutures remain in place for 12 to 18 months. Potential complications include early graft failure due to poor quality of donor tissue, surgical trauma, acute infection, and persistently increased IOP and late graft failure due to rejection. Postoperatively, the patient receives mydriatic medications (2 weeks) and topical corticosteroids (12 months; daily doses for 6 months and tapered doses thereafter). Patients typically describe a sensation of postoperative eye discomfort rather than acute pain.
Nursing Management The nurse reinforces the surgeon’s recommendations and instructions regarding visual rehabilitation and visual improvement by explaining why a technically successful graft may initially produce disappointing results because the procedure has produced a new optical surface and only after several months do patients start seeing the natural and true colors of their environment. Correction of a resultant refractive error with eyeglasses or contact lenses determines the final visual outcome. The nurse assesses the patient’s support system and his or her ability to comply with longterm follow-up, which includes frequent clinic visits for several months for tapering of topical corticosteroid therapy, selective suture removal, and ongoing evaluation of the graft site and visual
Chart 58-7
Contraindications to the Use of Donor Tissue for Corneal Transplantation: Donor Characteristics
Systemic Disorders • Death from unknown cause • Creutzfeldt-Jacob disease • AIDS or high risk for HIV infection • Hepatitis • Eye infection, systemic infection Intrinsic Eye Disease • Retinoblastoma • Ocular inflammation • Malignant tumors of anterior segment • Disorders of the conjunctiva or corneal surface involving the optical zone of the cornea Other • History of eye trauma • Corneal scars • Previous surgical procedure • Corneal graft • LASIK eye surgery
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acuity. The nurse also initiates appropriate referral to community services when indicated. Because graft failure is an ophthalmic emergency that can occur at any time, the primary goal of nursing care is to teach the patient to identify signs and symptoms of graft failure. The early symptoms are blurred vision, discomfort, tearing, or redness of the eye. Decreased vision results after graft destruction. Patients must contact the ophthalmologist as soon as symptoms occur. Treatment of graft rejection is prompt administration of hourly topical corticosteroids and periocular corticosteroid injections. Systemic immunosuppressive agents may be necessary for severe, resistant cases.
REFRACTIVE SURGERIES Refractive surgeries are cosmetic, elective procedures performed to reshape corneal tissue and correct refractive errors so that eyeglasses or contact lenses are no longer needed. Current procedures include radial keratotomy, photorefactive keratectomy (PFK), and LASIK. Refractive surgery alters the major optical function of the eye and thereby carries certain surgical risks. The patient must fully understand benefits, potential risks and complications, common side effects, and limitations of the procedure. Refractive surgery does not alter the normal aging process of the eye. If the reason for the procedure is occupational vision requirements, the results must satisfy both the patient and the employer. Precise visual outcome cannot be guaranteed with certainty. Typically, patients must be at least 18 years of age. The corneal structure must be normal and refractive error stable. Patients are required to discontinue using contact lenses for a period before the procedure (ie, 2 to 3 weeks for soft lenses and 4 weeks for hard lenses). Patients with conditions that are likely to adversely affect corneal wound healing (eg, corticosteroid use, immunosuppression, elevated IOP) are not good candidates for the procedure. Any superficial eye disease must be diagnosed and fully treated before a refractive procedure.
Radial Keratotomy Radial keratotomy (RK) is indicated for low myopia (less than 8D). The procedure involves making four to eight, deep, radial incisions in the paracentral and peripheral cornea with a metal or diamond blade. The corneal contour then becomes flatter. Glare, photosensitivity, fluctuations of vision during the day, and occasional diplopia are common side effects. As the popularity of laser refractive surgery grows, RK procedures decrease.
been associated with the two major disadvantages of RK: hyperopic drift and weakening of the structural integrity of the cornea.
Laser-Assisted In Situ Keratomileusis (LASIK) An improvement over PRK, particularly for correcting high (severe) myopia, LASIK involves flattening the anterior curvature of the cornea by removing a stromal lamella or layer. The surgeon creates a corneal flap with a microkeratome, which is an automatic corneal shaper similar to a carpenter’s plane. The surgeon retracts a flap of corneal tissue less than one third of the thickness of a human hair to access the corneal stroma and then uses the excimer laser on the stromal bed to reshape the cornea according to calculated measurements (Fig. 58-10). The corneal flap, a naturally adhering bandage, is rolled back and repositioned. LASIK also appears to be an effective, predictable, stable, and safe procedure for correcting residual myopia after cataract surgery (Ayala et al., 2001). LASIK causes less postoperative discomfort, has fewer side effects, and is safer than PRK. The patient has no corneal haze and requires less postoperative care. With LASIK, however, the cornea has been invaded at a deeper level, and any complications are more significant than those that can occur with PRK. PERIOPERATIVE COMPLICATIONS Ablation-Related Complications. Ablation complications of LASIK include an elevated area within the corneal treatment ablation zone (ie, central island). Signs and symptoms of this complication include ghosting, blurred vision, halo formation around lights, decreased visual activity, and contrast sensitivity in low light. Most of the island formations resolve over time; reablation is considered only after the island appears stable after repeated examinations for at least 3 months. Diffuse Lamellar Keratitis. As LASIK increases in popularity and is performed more often, the vision-threatening complication known as diffuse lamellar keratitis (DLK) is reported more often. DLK is a peculiar, noninfectious, inflammatory reaction in the lamellar interface after LASIK. DLK is characterized by a white, granular, diffuse, culture-negative lamellar keratitis occurring in
Laser Vision Correction Photorefractive Keratectomy Laser vision correction photorefractive keratectomy (PRK) is a procedure used to treat myopia and hyperopia with or without astigmatism. The 193-mm argon fluoride excimer laser is applied directly to the cornea according to carefully calculated measurements. For myopia, the relative curvature is decreased; for hyperopia, the relative curvature is increased. A bandage contact lens is placed over the cornea to promote epithelial healing and reduce pain similar to that of severe corneal abrasion. PRK requires a longer visual recovery period than RK, but PRK provides more predictable and stable results. Except for the side effect of corneal haze and night vision problems, PRK has not
FIGURE 58-10 LASIK combines delicate surgical procedures and laser treatment. A flap is surgically created and lifted to one side. A laser is then applied to the cornea to reshape it. With permission from The Wilmer Laser Vision Center, Lutherville, MD.
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the first week after surgery. Studies suggest that, because no single agent appears to be solely the cause of DLK, the cause is multifactorial (Holland et. al., 2000). DLK is diagnosed by identifying cells in the lamellar interface by slit-lamp examination from postoperative day 1. Depending on the severity of the condition, treatment methods range from administering corticosteroid drops to intervening surgically. Central Islands and Decentered Ablations. Decentered or eccentric ablation involves a shift of the center of the ablation pattern from the pupil or visual axis to a more eccentric location. Symptoms include decreased visual acuity, halos, glare, and ghosting, especially in low-light settings.
LASIK Enhancements LASIK enhancements are surgical options from improved technology and software used to treat a wider range of myopia, hyperopia, and astigmatism in eyes with a history of LASIK surgery. Astigmatic keratotomy continues to work well for patients with significant regular astigmatism. A newer procedure, Intacs implantation, is performed for patients left with significant myopia but who have thin corneas. Hyperopic excimer laser enhancements are indicated for patients who have undergone myopic LASIK and have consecutive hyperopia. IMPLANTABLE DEVICES Because the results of refractive surgery on high (severe) myopia, hyperopia, and astigmatism are less predictable, there has been increasing interest in the use of phakic IOLs. Anterior and posterior chamber IOLs are now in use, and design improvements continue to be made. Phakic IOL implantation does not compromise the central optical zone and retains the normal aspheric contour of the cornea. Most importantly, it is reversible. Early research results on vision quality favor phakic IOL over LASIK. Potential complications include cataract, iritis or uveitis, endothelial cell loss, and increased IOP. Intacs is an implantable intrastromal corneal ring used to correct mild to moderate myopia. The intrastromal corneal ring segments are placed in the corneal stroma outside of the central optical zone and reshape the anterior surface of the cornea.
RETINAL DETACHMENT Retinal detachment refers to the separation of the RPE from the sensory layer. The four types of retinal detachment are rhegmatogenous, traction, a combination of rhegmatogenous and traction, and exudative. Rhegmatogenous detachment is the most common form. In this condition, a hole or tear develops in the sensory retina, allowing some of the liquid vitreous to seep through the sensory retina and detach it from the RPE (Fig. 58-11). People at risk for this type of detachment include those with high myopia or aphakia after cataract surgery. Trauma may also play a role in rhegmatogenous retinal detachment. Between 5% and 10% of all rhegmatogenous retinal detachments are associated with proliferative retinopathy, a retinopathy associated with diabetic neovascularization (see Chap. 41). Tension, or a pulling force, is responsible for traction retinal detachment. An ophthalmologist must ascertain all of the areas of retinal break and identify and release the scars or bands of fibrous material providing traction on the retina. Generally, patients with this condition have developed fibrous scar tissue from conditions such as diabetic retinopathy, vitreous hemorrhage, or the retinopathy of prematurity. The hemorrhages and fibrous proliferation associated with these conditions exert a pulling force on the delicate retina. Patients can have both rhegmatogenous and traction retinal detachment. Exudative retinal detachments are the result of the production of a serous fluid under the retina from the choroid. Conditions such as uveitis and macular degeneration may cause the production of this serous fluid.
Clinical Manifestations Patients may report the sensation of a shade or curtain coming across the vision of one eye, cobwebs, bright flashing lights, or the sudden onset of a great number of floaters. Patients do not complain of pain.
Assessment and Diagnostic Findings After visual acuity is determined, the patient must have a dilated fundus examination using an indirect ophthalmoscope and a Goldmann three-mirror examination. This examination is detailed Detached retina
Management Patient satisfaction is the ultimate goal; therefore, patient education and counseling about potential risks, complications, and postoperative follow-up are critical. Minimal postoperative care includes topical corticosteroid drops. The length of postoperative follow-up depends on the refractive procedure, with PRK requiring a longer course, followed by RK and then LASIK.
Retinal tear Lens
Retinal Disorders Although the retina is composed of multiple microscopic layers, the two innermost layers, the sensory retina and the retinal pigment epithelium (RPE), are the most relevant to common retinal disorders. Just as the film in a camera captures an image, so does the retina, the neural tissue of the eye. The rods and cones, the photoreceptor cells, are found in the sensory layer of the retina. Beneath the sensory layer lies the RPE, the pigmented layer. When the rods and cones are stimulated by light, an electrical impulse is generated, and the image is transmitted to the brain.
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Fluid
Vitreous humor
FIGURE 58-11
Retinal detachment.
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and prolonged, and it can be very uncomfortable for the patient. Many patients describe this as looking directly into the sun. All retinal breaks, all fibrous bands that may be causing traction on the retina, and all degenerative changes must be identified. A detailed retinal drawing is made by the ophthalmologist.
Surgical Management In rhegmatogenous detachment, an attempt is made to reattach the sensory retina to the RPE surgically. The retinal surgeon compresses the sclera (often with a scleral buckle or a silicone band; Fig. 58-12) to indent the scleral wall from the outside of the eye and bring the two retinal layers in contact with each other. Gas bubbles, silicone oil, or perfluorocarbon and liquids may also be injected into the vitreous cavity to help push the sensory retina up against the RPE. Argon laser photocoagulation or cryotherapy is also used to “spot-weld” small holes. In traction retinal detachment, a vitrectomy is performed. A vitrectomy is an intraocular procedure in which 1- to 4-mm incisions are made at the pans plana. One incision allows the introduction of a light source (ie, endoilluminator), and another incision serves as the portal for the vitrectomy instrument. The surgeon dissects preretinal membranes under direct visualization while the retina is stabilized by an intraoperative vitreous substitute. Technologic advances, including the use of operating microscopes, microinstrumentation, irrigating contact lenses, and instruments that combine vitreous cutting, aspiration, and illumination capabilities into one device, have allowed tremendous progress in vitreoretinal surgery. The techniques of vitreoretinal surgery can be used in various procedures, including the removal of foreign bodies, vitreous opacities such as blood, and dislocated lenses. Traction on the retina may be relieved through vitrectomy and may be combined with scleral buckling to repair retinal breaks. Treatment of macular holes includes vitrectomy, laser photocoagulation, air-fluid-gas exchanges, and the use of growth factor.
Nursing Management For the most part, nursing interventions consist of educating the patient and providing supportive care. Scleral buckle encircles globe
Buckle holds sclera against the retina
Repaired tear
FIGURE 58-12
Scleral buckle.
PROMOTING COMFORT If gas tamponade is used to flatten the retina, the patient may have to be specially positioned to make the gas bubble float into the best position. Some patients must lie face down or on their side for days. Patients and family members should be made aware of these special needs beforehand, so that the patient can be made as comfortable as possible. TEACHING ABOUT COMPLICATIONS In many cases, vitreoretinal procedures are performed on an outpatient basis, and the patient is seen the next day for a follow-up examination and closely monitored thereafter as required. Postoperative complications in these patients may include increased IOP, endophthalmitis, development of other retinal detachments, development of cataracts, and loss of turgor of the eye. Patients must be taught the signs and symptoms of complications, particularly of increasing IOP and postoperative infection.
RETINAL VASCULAR DISORDERS Loss of vision can occur from occlusion of a retinal artery or vein. Such occlusions may result from atherosclerosis, cardiac valvular disease, venous stasis, hypertension, or increased blood viscosity.
Central Retinal Vein Occlusion Blood supply to and from the ocular fundus is provided by the central retinal artery and vein. Patients who have suffered a central retinal vein occlusion report decreased visual acuity, which may range from mild blurring to vision that is limited to only hand-motion vision. Direct ophthalmoscopy of the retina shows optic disc swelling, venous dilation and tortuousness, retinal hemorrhages, cottonwool spots, and a “blood and thunder” (extremely bloody) appearance of the retina. The better the initial visual acuity, the better the general prognosis. Fluorescein angiography may show extensive areas of capillary closure. The patient should be monitored carefully over the ensuing several months for signs of neovascularization and neovascular glaucoma. Laser panretinal photocoagulation may be necessary to treat the abnormal neovascularization. Neovascularization of the iris may cause neovascular glaucoma, which may be difficult to control.
Branch Retinal Vein Occlusion Some patients with branch retinal vein occlusions are symptom free, whereas others complain of a sudden loss of vision if the macular area is involved. A more gradual loss of vision may occur if macular edema associated with the branch retinal vein occlusion develops. On examination, the ocular fundus appears similar to that found with central retinal vein occlusion; however, only those portions of the retina affected by the obstructive veins have what is known as a “blood and thunder” appearance. The diagnostic evaluation and follow-up assessments are the same as for central retinal vein occlusion. Potential complications are similar. Potential associated conditions include glaucoma, systemic hypertension, diabetes mellitus, hyperlipidemia, and hyperviscosity syndrome.
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Central Retinal Artery Occlusion The patient with central retinal artery occlusion presents with a sudden loss of vision. Visual acuity is reduced to counting the examiner’s fingers, or the field of vision is tremendously restricted. A relative afferent pupillary defect is present. Examination of the ocular fundus reveals a pale retina with a cherry-red spot at the fovea. The retinal arteries are thin, and emboli are occasionally seen in the central retinal artery or its branches. Central retinal artery occlusion is a true ocular emergency. Various treatments are used, including ocular massage, anterior chamber paracentesis, intravenous administration of hyperosmotic agents such as acetazolamide, and high concentrations of oxygen.
MACULAR DEGENERATION Macular degeneration is the most common cause of visual loss in people older than age 60 (Margolis et al., 2002). Commonly called age-related macular degeneration (AMD), it is characterized by tiny, yellowish spots called drusen (Fig. 58-13) beneath the retina. Most people older than 60 years of age have at least a few small drusen. There is a wide range of visual loss in patients with macular degeneration, but most patients do not experience total blindness. Central vision is generally the most affected, with most patients retaining peripheral vision (Fig. 58-14). There are two types of AMD, commonly known as the dry type and wet type. Between 85% and 90% of people with AMD have the dry or nonexudative type in which the outer layers of the retina slowly break down (Fig. 58-15). With this breakdown comes the appearance of drusen. When the drusen occur outside of the macular area, patients generally have no symptoms. When the drusen occur within the macula, there is a gradual blurring of vision that patients may notice when they try to read. There is no known treatment that can slow or cure this type of AMD. The second type of AMD, the wet or exudative type, may have an abrupt onset. Patients complain that straight lines appear crooked and distorted or that letters in words appear broken up. This effect results from proliferation of abnormal blood vessels growing under the retina, within the choroid layer of the eye, a condition known as choroidal neovascularization (CNV). The affected vessels can leak fluid and blood, elevating the retina. Some patients can be treated with the laser to stop the leakage from these vessels. This treatment is not ideal because vision may
FIGURE 58-14
Visual loss associated with macular degeneration.
be affected by the laser treatment and abnormal vessels often grow back after treatment.
Medical Management PHOTODYNAMIC THERAPY Visual loss from CNV lesions in AMD is a growing problem. With the growth of these new vessels from the choriocapillar layer, fibrous tissue develops that can, over months, destroy central vision. Laser treatment has been used to close these abnormal vessels, but the very process of photocoagulation carries with it some level of retinal destruction, albeit less than the natural scarring that would occur in the untreated eye. Photodynamic therapy (PDT) has been developed in an attempt to ameliorate the CNV while causing minimal damage to the retina. The Treatment of Age-Related Macular Degeneration With Photodynamic Therapy (TAP) study group (1999) has shown that PDT can reduce the risk of visual loss for certain groups of patients who have classic subfoveal choroidal neovascularization due to macular degeneration. PDT is a two-step process (Fig. 58-16). Verteporfin, a photosensitive dye, is infused intravenously over 10 minutes. Fifteen minutes after the start of the infusion, a diode laser is used to treat the abnormal network of vessels. The dye within the vessels takes up the energy of the diode laser, but the surrounding retina does not, avoiding damage to adjacent areas. Retreatment may be necessary over time.
Nursing Management
FIGURE 58-13
Retina showing drusen and AMD.
Nursing management is primarily educational. Verteporfin is a light-activated dye, and patient education is important preoperatively. The patient should be instructed to bring dark sunglasses, gloves, a wide-brimmed hat, long-sleeved shirt, and slacks to the PDT setting. The patient must be cautioned to avoid exposure to direct sunlight or bright light for 5 days after treatment. The dye within the blood vessels near the surface of the skin could become activated with exposure to strong light. This would include bright sunlight, tanning booths, halogen lights, and the bright lights used in dental offices and operating rooms. Ordinary indoor light is not a problem. If a patient must go outdoors within the first 5 days after treatment, he or she should be counseled to wear
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Risk factors • Increasing age • Smoking history • Hypertension • Overweight • Hyperopia • Familial incidence • Wet AMD (more common in Caucasians than African Americans) • Use of thyroid hormones and hydrochlorothiazides • Arthritis
Drusen (yellowish spots associated with aging) appear in retina. No visual symptoms if not located in macula. May vary in size.
"Dry" or nonneovascular AMD: Macular drusen may coalesce, causing gradual decrease in central vision. Missing letters in words, blank spots, geographic atrophy, and retinal pigment epithelial abnormalities may appear.
"Wet" or neovascular AMD: Characterized by the development of an abnormal choroidal neovascular network beneath the macula. These vessels leak fluid and bleed, causing edema and the development of fibrosis. Visual changes can occur rapidly. Straight lines appear crooked and distorted. The resulting macular disciform scar causes a loss of central vision.
Loss of central vision
FIGURE 58-15
Progression of age-related macular degeneration (AMD): pathways to vision loss.
long-sleeved shirts and slacks made of tightly woven fabrics. Gloves, shoes, socks, sunglasses, and a wide-brimmed hat should also be worn if the patient has to go outdoors during daylight hours during this period. Inadvertent sunlight exposure can lead to severe blistering of the skin and sunburn that may require plastic surgery.
area of CNV. Laser treatment can then be applied to the abnormal neovascular network with minimal damage occurring to the macula. Pilot studies are evaluating whether this surgical approach is an effective alternative to laser treatments of CNV due to AMD.
Angiogenesis Macular Translocation Wet macular degeneration is characterized by the development of an abnormal CNV membrane to the detriment of central vision. One approach to this problem is the surgical procedure known as macular translocation, in which a 360-degree retinal detachment is surgically created and the retina is gently lifted and resettled, placing the macular area a slight distance away from the
An important component of the effort against neovascular AMD is the investigation into the causes of the development and progression of angiogenesis (ie, abnormal blood vessel formation). Investigations continue in the laboratory to search for agents that can inhibit angiogenesis. This has implications for ocular neovascularization and treatment of other disorders such as solid tumors.
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to determine whether large doses of macronutrients are effective in preventing or slowing the course of AMD. The study revealed that use of antioxidants (ie, vitamin C, vitamin E, and betacarotene) and minerals (ie, zinc oxide) can slow the progression of AMD and vision loss for people at high risk for developing advanced AMD.
Orbital and Ocular Trauma Whether affecting the eye or the orbit, trauma to the eye and surrounding structures may have devastating consequences for vision. It is preferable to prevent injury rather than treat it. Chart 58-8 details safety measures to prevent orbital and ocular trauma.
ORBITAL TRAUMA Injury to the orbit is usually associated with a head injury; hence, the patient’s general medical condition must first be stabilized before conducting an ocular examination. Only then is the globe assessed for soft tissue injury. During inspection, the face is meticulously assessed for underlying fractures, which should always be suspected in cases of blunt trauma. To establish the extent of ocular injury, visual acuity is assessed as soon as possible, even if it is only a rough estimate. Soft tissue orbital injuries often result in damage to the optic nerve. Major ocular injuries indicated by a soft globe, prolapsing tissue, ruptured globe, hemorrhage, and loss of red reflex require immediate surgical attention.
Soft Tissue Injury and Hemorrhage FIGURE 58-16 Photodynamic therapy (PDT) for slowing progression of age-related macular degeneration. Light-sensitive verteporfin dye is injected into defective vessels. A special laser activates the dye, which releases singlet oxygen that is toxic to endothelial cells, shutting down the vessels without damaging the retina. With permission from Valenz, K. D. (2001). Laser surgery shines as ray of hope. Helix 18(3):12–13. Management Most patients benefit from the use of bright lighting and magnification devices and from referral to a low-vision center. Some low-vision centers send representatives into the patient’s home or place of employment to evaluate the living and working conditions and make recommendations to improve lighting, thereby improving vision and promoting safety. The home care nurse can make the same assessment and recommendations. Amsler grids are given to patients to use in their home to monitor for a sudden onset or distortion of vision. These may provide the earliest sign that macular degeneration is getting worse. Patients should be encouraged to use these grids and to look at them, one eye at a time, several times each week with glasses on. If there is a change in the grid (eg, if the lines or squares appear distorted or faded), the patient should be instructed to notify the ophthalmologist immediately and to arrange to be seen promptly. The Age-Related Eye Disease Study Group (2001), a multicenter clinical trial, has provided promising information about the prevention and treatment of AMD. The study was designed
The signs and symptoms of soft tissue injury from blunt or penetrating trauma include tenderness, ecchymosis, lid swelling, proptosis (ie, downward displacement of the eyeball), and hemorrhage. Closed injuries lead to contusions with subconjunctival hemorrhage, commonly known as a black eye. Blood accumulates in the tissues of the conjunctiva. Hemorrhage may be caused by a soft tissue injury to the eyelid or by an underlying fracture. Management of soft tissue hemorrhage that does not threaten vision is usually conservative and consists of thorough inspection, cleansing, and repair of wounds. Cold compresses are used in the early phase, followed by warm compresses. Hematomas that appear as swollen, fluctuating areas may be surgically drained or aspirated; if they are causing significant orbital pressure, they may be surgically evacuated. Penetrating injuries or severe blow to the head can result in severe optic nerve damage. Visual loss can be sudden or delayed and progressive. Immediate loss of vision after an ocular injury is usually irreversible. Delayed visual loss has a better prognosis. Corticosteroid therapy is indicated to reduce optic nerve swelling. Surgery, such as optic nerve decompression, may be performed.
Orbital Fractures Orbital fractures are detected by facial x-rays. Depending on the orbital structures involved, orbital fractures can be classified as blow-out, zygomatic or tripod, maxillary, midfacial, orbital apex, and orbital roof fractures. Blow-out fractures result from compression of soft tissue and sudden increase in orbital pressure when the force is transmitted to the orbital floor, the area of least resistance.
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Chart 58-8 Health Promotion • Preventing Eye Injuries In and Around the House • Make sure that all spray nozzles are directed away from you before you press down on the handle. • Read instructions carefully before using cleaning fluids, detergents, ammonia, or harsh chemicals. Wash hands thoroughly after use. • Use grease shields on frying pans to decrease spattering. • Wear special goggles to shield your eyes from fumes and splashes when using powerful chemicals. • Use opaque goggles to avoid burns from sunlamps. In the Workshop • Protect your eyes from flying fragments, fumes, dust particles, sparks, and splashed chemicals by wearing safety glasses. • Read instructions thoroughly before using tools and chemicals, and follow precautions for their use. Around Children • Pay attention to age and maturity level of a child when selecting toys and games. Avoid projectile toys, such as darts and pellet guns. • Supervise children when they are playing with toys or games that can be dangerous. • Teach children the correct way to handle potentially dangerous items, such as scissors and pencils. In the Garden • Do not let anyone stand at the side of or in front of a moving lawn mower. • Pick up rocks and stones before going over them with the lawn mower. These stones can be hurled out of the rotary
The inferior rectus and inferior oblique muscles, with their fat and fascial attachments, or the nerve that courses along the inferior oblique muscle may become entrapped, and the globe may be displaced inward (ie, enophthalmos). Computed tomography (CT) can firmly identify the muscle and its auxiliary structures that are entrapped. These fractures are usually caused by blunt small objects, such as a fist, knee, elbow, or tennis or golf balls. Orbital roof fractures are dangerous because of potential complications to the brain. Surgical management of these fractures requires a neurosurgeon and an ophthalmologist. The most common indications for surgical intervention are displacement of bone fragments disfiguring the normal facial contours, interference with normal binocular vision caused by extraocular muscle entrapment, interference with mastication in zygomatic fracture, and obstruction of the nasolacrimal duct. Surgery is usually nonemergent, and a period of 10 to 14 days gives the ophthalmologist time to assess ocular function, especially the extraocular muscles and the nasolacrimal duct. Emergency surgical repair is usually not performed unless the globe is displaced to the maxillary sinus. Operative repair is primarily directed at freeing the entrapped ocular structures and restoring the integrity of the orbital floor. Cosmetic surgery for deformities of the globe and enophthalmos may follow after 4 to 6 months, but successful repair is usually difficult.
Foreign Bodies Foreign bodies that enter the orbit are usually tolerated, except for copper, iron, and vegetable materials such as those from plants or trees, which may cause purulent infection. X-rays and
blades and rebound off curbs or walls, causing severe injury to the eye. • Make sure that pesticide spray can nozzles are directed away from your face. • Avoid low-hanging branches. Around the Car • Before opening the hood of the car, put out all smoking materials and matches. Use a flashlight, not a match or lighter, to look at the battery at night. • Wear goggles when grinding metal or striking metal against metal while performing auto body repair. • When using jumper cables to start the car, wear goggles; make sure the cars are not touching one another; make sure the jumper cable clamps never touch each other; never lean over the battery when attaching cables. Never attach a cable to the negative terminal of the dead battery. In Sports • Wear protective safety glasses, especially for sports such as racquetball, squash, tennis, baseball, and basketball. • Wear protective caps, helmets, or face protectors when appropriate, especially for sports such as ice hockey. Around Fireworks • Wear eye glasses or safety goggles. • Do not use explosive fireworks. • Never allow children to ignite fireworks. • Do not stand near others when lighting fireworks. • Do not try to relight duds. Douse them in water.
CT scans are used to identify the foreign body. Careful history taking is important, especially if the foreign body has been in the orbit for a period of time and the incident forgotten. It is important to identify metallic foreign bodies because they prohibit the use of magnetic resonance imaging (MRI) as a diagnostic tool. After the extent of the orbital damage is assessed, the decision is made between conservative treatment and surgical removal. In general, orbital foreign bodies are usually removed if they are superficial and anterior in location, have sharp edges that may affect adjacent orbital structures, or are composed of copper, iron, or vegetable material. The surgical intervention is directed at prevention of further ocular injury and maintaining the integrity of the affected areas. Cultures are usually obtained, and the patient is placed on prophylactic intravenous antibiotics that are later changed to oral antibiotics.
OCULAR TRAUMA Ocular trauma is the leading cause of blindness among children and young adults, especially male trauma victims. The most common circumstances of ocular trauma are occupational injuries (eg, construction industry), sports (eg, baseball, basketball, racket sports, boxing), weapons (eg, air guns, BB guns), assault, motor vehicle crashes (eg, broken windshields), and war (eg, blast fragments). For the nonophthalmic practitioner, initial intervention is performed in only two conditions: chemical burns, for which irrigation of the eye with normal saline solution or even plain tap water must occur immediately, and a foreign body, for which
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absolutely no attempt is made to remove the foreign material, small or big, or apply pressure or patch to the injured eye. The eye must be protected using a metal shield, if available, or a stiff paper cup (Fig. 58-17). All traumatic eye injuries should be properly shielded.
lead to permanent corneal scarring. Corticosteroids are avoided while the epithelial defect exists.
Assessment and Diagnostic Findings
Sharp penetrating injury or blunt contusion force can rupture the eyeball. When the eye wall, cornea, and sclera rupture, rapid decompression or herniation of the orbital contents into adjacent sinuses can occur. In general, blunt traumatic injuries (with an increased incidence of retinal detachment, intraocular tissue avulsion, and herniation) have a worse prognosis than penetrating injuries. Most penetrating injuries result in marked loss of vision with the following signs: hemorrhagic chemosis (ie, edema of the conjunctiva), conjunctival laceration, shallow anterior chamber with or without an eccentrically placed pupil, hyphema (ie, hemorrhage within the chamber), or vitreous hemorrhage. Hyphema is caused by contusion forces that tear the vessels of the iris and damage the anterior chamber angle. Preventing rebleeding and prolonged increased IOP are the goals of treatment for hyphema. In severe cases in which patient compliance is questionable, the patient is hospitalized with moderate activity restriction. An eye shield is applied. Topical corticosteroids are prescribed to reduce inflammation. An antifibrinolytic agent, aminocaproic acid (Amicar), stabilizes clot formation at the site of hemorrhage. Aspirin is contraindicated. A ruptured globe and severe injuries with intraocular hemorrhage require surgical intervention. Vitrectomy is performed for traumatic retinal detachments. Primary enucleation (ie, complete removal of the eyeball and part of the optic nerve) is considered only if the globe is irreparable and has no light perception. It is a general rule that enucleation is performed within 2 weeks of the initial injury (in an eye that has no useful vision after sustaining penetrating injury) to prevent the risk of sympathetic ophthalmia, an inflammation created in the fellow eye by the affected eye that can result in blindness of the fellow eye.
A thorough history is obtained, particularly assessing the patient’s ocular history, such as preinjury vision in the affected eye or past ocular surgery. Details related to the injury that help in the diagnosis and assessment of need for further tests include the nature of the ocular injury (ie, blunt or penetrating trauma), the type of activity causing the injury to determine the nature of the force striking the eye, and whether onset of vision loss was sudden, slow, or progressive. For chemical eye burns, the chemical agent must be identified and tested for pH if a sample is available. The corneal surface is examined for foreign bodies, wounds, and abrasions, after which the other external structures of the eye are examined. Pupillary size, shape, and light reaction of the pupil of the affected eye are compared with the other eye. Ocular motility, which is the ability of the eyes to move synchronously up, down, right, and left, is also assessed.
Medical Management SPLASH INJURIES Splash injuries are irrigated with normal saline solution before further evaluation. In cases of ruptured globe, cycloplegic agents (ie, agents that paralyze the ciliary muscle) or topical antibiotics must be deferred because of potential toxicity to exposed intraocular tissues. Further manipulation of the eye must be avoided until the patient is under general anesthesia. Parenteral, broadspectrum antibiotics are initiated. Tetanus antitoxin is administered, if indicated, as well as analgesics. (Tetanus prophylaxis is recommended for full-thickness ocular and skin wounds.) Any topical medication (eg, anesthetic, dyes) must be sterile. FOREIGN BODIES AND CORNEAL ABRASIONS After removal of a foreign body from the surface of the eye, an antibiotic ointment is applied, and the eye is patched. The eye is examined daily for evidence of infection until the wound is completely healed. Contact lens wear is a common cause of corneal abrasion. The patient experiences severe pain and photophobia (ie, ocular pain on exposure to light). Corneal epithelial defects are treated with antibiotic ointment and a pressure patch to immobilize the eyelids. It is of utmost importance that topical anesthetic eye drops are not given to a patient for repeated use after corneal injury because their effects mask further damage, delay healing, and can
Penetrating Injuries and Contusions of the Eyeball
Intraocular Foreign Bodies A patient who complains of blurred vision and discomfort should be questioned carefully about recent injuries and exposures. Patients may be injured in a number of different situations and suffer an intraocular foreign body (IOFB). Precipitating circumstances can include working in construction, striking metal against metal, being involved in motor vehicle crashes with facial injury, gunshot wounds, and grinding-wheel work. IOFB is diagnosed and localized by slit-lamp biomicroscopy and indirect ophthalmoscopy, as well as CT or ultrasonography. MRI is contraindicated because most foreign bodies are metallic
FIGURE 58-17
Two kinds of eye patches. (A) Metal shield. (B) Stiff paper cup shield (innovative substitute when metal shield is unavailable). Adapted from MacCumber, M. W. (Ed.). (1997). Management of ocular injuries and emergencies. Philadelphia: LippincottRaven.
A
B
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and magnetic. It is important to determine the composition, size, and location of the IOFB and affected eye structures. Every effort should be made to identify the type of IOFB and whether it is magnetic. Iron, steel, copper, and vegetable matter cause intense inflammatory reactions. The incidence of endophthalmitis is also high. If the cornea is perforated, tetanus prophylaxis and intravenous antibiotics are administered. The extraction route (ie, surgical incision) of the foreign body depends on its location and composition and associated ocular injuries. Specially designed IOFB forceps and magnets are used to grasp and remove the foreign body. Any damaged area of the retina is treated to prevent retinal detachment.
OCULAR BURNS Alkali, acid, and other chemically active organic substances, such as mace and tear gas, cause chemical burns. Alkali burns (eg, lye, ammonia) result in the most injury because they penetrate the ocular tissues rapidly and continue to cause damage long after the initial injury is sustained. They also cause an immediate rise in IOP. Acids (eg, bleach, car batteries, refrigerant) generally cause less damage because the precipitated necrotic tissue proteins form a barrier to further penetration and damage. Chemical burns may appear as superficial punctate keratopathy (ie, spotty damage to the cornea), subconjunctival hemorrhage, or complete marbleizing of the cornea. In treating chemical burns, every minute counts. Immediate tap-water irrigation should be started on site before transport of the patient to an emergency department. Only a brief history and examination are performed. The corneal surfaces and conjunctival fornices are immediately and copiously irrigated with normal saline or any neutral solution. A local anesthetic is instilled, and a lid speculum is applied to overcome blepharospasm (ie, spasms of the eyelid muscles that result in closure of the lids). Particulate matter must be removed from the fornices using moistened, cottontip applicators and minimal pressure on the globe. Irrigation continues until the conjunctival pH normalizes (between 7.3 and 7.6). The pH of the corneal surface is checked by placing a pH paper strip in the fornix. Antibiotics are instilled, and the eye is patched. The goal of intermediate treatment is to prevent tissue ulceration and promote re-epithelialization. Intense lubrication using nonpreserved (ie, without preservatives to avoid allergic reactions) tears is essential. Re-epithelialization is promoted with patching or therapeutic soft lenses. The patient is usually monitored daily for several days. Prognosis depends on the type of injury and adequacy of the irrigation immediately after exposure. Long-term treatment consists of two phases: restoration of the ocular surface through grafting procedures and surgical restoration of corneal integrity and optical clarity. Thermal injury is caused by exposure to a hot object (eg, curling iron, tobacco, ash), whereas photochemical injury results from ultraviolet irradiation or infrared exposure (eg, exposure to the reflections from snow, sun gazing, viewing an eclipse of the sun without an adequate filter). These injuries can cause corneal epithelial defect, corneal opacity, conjunctival chemosis and injection (ie, congestion of blood vessels), and burns of the eyelids and periocular region. Antibiotics and a pressure patch for 24 hours constitute the treatment of mild injuries. Scarring of the eyelids may require oculoplastic surgery, whereas corneal scarring may require corneal surgery.
Infectious and Inflammatory Conditions Inflammation and infection of eye structures are common. Eye infection is a leading cause of blindness worldwide. Table 58-7 describes selected common infections and their treatment.
DRY EYE SYNDROME Dry eye syndrome, or keratoconjunctivitis sicca, is a deficiency in the production of any of the aqueous, mucin, or lipid tear film components; lid surface abnormalities; or epithelial abnormalities related to systemic diseases (eg, thyroid disorders, Parkinson’s disease), infection, injury, or complications of medications (eg, antihistamines, oral contraceptives, phenothiazines).
Clinical Manifestations The most common complaint in dry eye syndrome is a scratchy or foreign body sensation. Other symptoms include itching, excessive mucus secretion, inability to produce tears, a burning sensation, redness, pain, and difficulty moving the lids.
Assessment and Diagnostic Findings Slit-lamp examination shows an absent or interrupted tear meniscus at the lower lid margin, and the conjunctiva is thickened, edematous, hyperemic, and has lost its luster. A tear meniscus is the crescent-shaped edge of the tear film in the lower lid margin. Chronic dry eyes may result in chronic conjunctival and corneal irritation that can lead to corneal erosion, scarring, ulceration, thinning, or perforation that can seriously threaten vision. Secondary bacterial infection can occur.
Management Management of dry eye syndrome requires the complete cooperation of the patient with a regimen that needs to be followed at home for a long period, or complete relief of symptoms is unlikely. Instillation of artificial tears during the day and an ointment at night is the usual regimen to hydrate and lubricate the eye through stimulating tears and preserving a moist ocular surface. Anti-inflammatory medications are also used, and moisture chambers (eg, moisture chamber spectacles, swim goggles) may provide additional relief. Patients may become hypersensitive to chemical preservatives such as benzalkonium chloride and thimerosal. For these patients, preservative-free ophthalmic solutions are used. Management of the dry eye syndrome also includes the concurrent treatment of infections, such as chronic blepharitis and acne rosacea, and treating the underlying systemic disease, such as Sjögren’s syndrome (an autoimmune disease). In advanced cases of dry eye syndrome, surgical treatment that includes punctal occlusion, grafting procedures, and lateral tarsorrhaphy (ie, uniting the edges of the lids) are options. Punctal plugs are made of silicone material for the temporary or permanent occlusion of the puncta. This helps preserve the natural tears and prolongs the effects of artificial tears. Short-term occlusion is performed by inserting punctal or silicone rods in all four puncta. If tearing is induced, the upper plugs are removed, and the remaining lower plugs are removed in another week. Permanent occlusion is performed only in severe cases among adults who do not develop tearing after partial occlusion and who have results
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• Common Infections and Inflammatory Disorders of Eye Structures
DISORDER
DESCRIPTION
MANAGEMENT
Hordeolum (sty)
Acute suppurative infection of the glands of the eyelids caused by Staphylococcus aureus. The lid is red and edematous with a small collection of pus in the form of an abscess. There is considerable discomfort.
Chalazion
Sterile inflammatory process involving chronic granulomatous inflammation of the meibomian glands; can appear as a single granuloma or multiple granulomas in the upper or lower eyelids.
Blepharitis
Chronic bilateral inflammation of the eyelid margins. There are two types: staphylococcal and seborrheic. Staphylococcal blepharitis is usually ulcerative and is more serious due to the involvement of the base of hair follicles. Permanent scarring can result. Infection of the cornea by S. aureus, Streptococcus pneumoniae, and Pseudomonas aeruginosa
Warm compresses are applied directly to the affected lid area three to four times a day for 10 to 15 minutes. If the condition is not improved after 48 hours, incision and drainage may be indicated. Application of topical antibiotics may be prescribed thereafter. Warm compresses applied three to four times a day for 10 to 15 minutes may resolve the inflammation in the early stages. Most often, however, surgical excision is indicated. Corticosteroid injection to the chalazion lesion may be used for smaller lesions. The seborrheic type is chronic and is usually resistant to treatment, but the milder cases may respond to lid hygiene. Staphylococcal blepharitis requires topical antibiotic treatment. Instructions on lid hygiene (to keep the lid margins clean and free of exudates) are given to the patient. Fortified (high-concentration) antibiotic eyedrops are administered every 30 minutes around the clock for the first few days, then every 1–2 hours. Systemic antibiotics may be administered. Cycloplegics are administered to reduce pain caused by ciliary spasm. Corticosteroid therapy and subconjunctival injections of antibiotics are controversial. Many lesions heal without treatment and residual effects. The treatment goal is to minimize the damaging effect of the inflammatory response and eliminate viral replication within the cornea. Penetrating keratoplasty is indicated for corneal scarring and must be performed when the herpetic disease has been inactive for many months.
Bacterial keratitis
Herpes simplex keratitis
Leading cause of corneal blindness in the United States. Symptoms are severe pain, tearing, and photophobia. The dendritic ulcer has a branching, linear pattern with feathery edges and terminal bulbs at its ends. Herpes simplex keratitis can lead to recurrent stromal keratitis and persist to 12 months with residual corneal scarring.
on a repeated Schirmer’s test of 2 mm or less (filter paper is used to measure tear production).
CONJUNCTIVITIS Conjunctivitis (ie, inflammation of the conjunctiva) is the most common ocular disease worldwide. It is characterized by a pink appearance (hence the common term pink eye) because of subconjunctival blood vessel hemorrhages.
Clinical Manifestations General symptoms include foreign body sensation, scratching or burning sensation, itching, and photophobia. Conjunctivitis may be unilateral or bilateral, but the infection usually starts in one eye and then spreads to the other eye by hand contact.
Assessment and Diagnostic Findings The four main clinical features important to evaluate are the type of discharge (ie, watery, mucoid, purulent, or mucopurulent), type of conjunctival reaction (ie, follicular or papillary), presence of pseudomembranes or true membranes, and presence or ab-
sence of lymphadenopathy (ie, enlargement of the preauricular and submandibular lymph nodes where the eyelids drain). Pseudomembranes consist of coagulated exudate that adheres to the surface of the inflamed conjunctiva. True membranes form when the exudate adheres to the superficial layer of the conjunctiva, and removal results in bleeding. Follicles are multiple, slightly elevated lesions encircled by tiny blood vessels; they look like grains of rice. Papillae are hyperplastic conjunctival epithelium in numerous projections that are usually seen as a fine mosaic pattern under slit-lamp examination. Diagnosis is based on the distinctive characteristics of ocular signs, acute or chronic presentation, and identification of any precipitating events. Positive results of swab smear preparations and cultures confirm the diagnosis.
Types of Conjunctivitis Conjunctivitis is classified according to its cause. The major causes are microbial infection, allergy, and irritating toxic stimuli. A wide spectrum of exogenous microbes can cause conjunctivitis, including bacteria (eg, Chlamydia), viruses, fungus, and parasites. Conjunctivitis can also result from infection of an existing ocular infection or can be a manifestation of a systemic disease.
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MICROBIAL CONJUNCTIVITIS Bacterial conjunctivitis can be acute or chronic. The acute type can develop into a chronic condition. Signs and symptoms can vary from mild to severe. Chronic bacterial conjunctivitis is usually seen in patients with lacrimal duct obstruction, chronic dacryocystitis, and chronic blepharitis. The most common causative microorganisms are Streptococcus pneumoniae, Haemophilus influenzae, and Staphylococcus aureus. Bacterial conjunctivitis manifests with an acute onset of redness, burning, and discharge. There is papillary formation, conjunctival irritation, and injection in the fornices. The exudates are variable but are usually present on waking in the morning. The eyes may be difficult to open because of adhesions caused by the exudate. Purulent discharge occurs in severe acute bacterial infections, whereas mucopurulent discharge appears in mild cases. In gonococcal conjunctivitis, the symptoms are more acute. The exudate is profuse and purulent, and there is lymphadenopathy. Pseudomembranes may be present. Viral conjunctivitis (Fig. 58-18) can also be acute and chronic. The discharge is watery, and follicles are prominent. Severe cases include pseudomembranes. The common causative organisms are adenovirus and herpes simplex virus. Conjunctivitis caused by adenovirus is highly contagious. The symptoms include extreme tearing, redness, and foreign body sensation that can involve one or both eyes. The condition is usually preceded by symptoms of upper respiratory infection. Corneal involvement causes extreme photophobia. There is lid edema, ptosis, conjunctival hyperemia (ie, dilation of the conjunctival blood vessels), watery discharge, follicles, and papillae. These signs and symptoms vary from mild to severe and may last for 2 weeks. Viral conjunctivitis, although self-limited, tends to last longer than bacterial conjunctivitis. Epidemic keratoconjunctivitis (EKC) is most often accompanied by preauricular lymphadenopathy and occasionally periorbital pain. There are marked follicular and papillary formations. EKC can lead to keratopathy. EKC is a highly contagious viral conjunctivitis that is easily transmitted from one person to another among household members, school children, and health care workers. The outbreak of epidemics is seasonal, especially during the summer when people frequent swimming pools. Chlamydial conjunctivitis includes trachoma and inclusion conjunctivitis. Trachoma is an ancient disease and is the leading cause of preventable blindness in the world. It is prevalent in areas with hot, dry, and dusty climates and in areas with poor living conditions. It is spread by direct contact or fomites, and the vectors can be insects such as flies and gnats.
Trachoma is a bilateral chronic follicular conjunctivitis of childhood that leads to blindness during adulthood, if left untreated. The onset in children is usually insidious, but it can be acute or subacute in adults. The initial symptoms include red inflamed eyes, tearing, photophobia, ocular pain, purulent exudates, preauricular lymphadenopathy, and lid edema. Initial ocular signs include follicular and papillary formations. At the middle stage of the disease, there is an acute inflammation with papillary hypertrophy and follicular necrosis, after which trichiasis (turning inward of hair follicles) and entropion begin to develop. The lashes that are turned in rub against the cornea and, after prolonged irritation, cause corneal erosion and ulceration. The late stage of the disease is characterized by scarred conjunctiva, subepithelial keratitis, abnormal vascularization of the cornea (pannus), and residual scars from the follicles that look like depressions in the conjunctiva (ie, Herbert’s pits). Severe corneal ulceration can lead to perforation and blindness. Inclusion conjunctivitis affects sexually active young people who have genital chlamydial infection. Transmission is by oralgenital sex or hand-to-eye transmission. It has been reported that indirect transmission has been acquired from inadequately chlorinated swimming pools. The eye lesions usually appear a week after exposure and may be associated with a nonspecific urethritis or cervicitis. The discharge is mucopurulent, follicles are present, and there is lymphadenopathy. ALLERGIC CONJUNCTIVITIS Immunologic or allergic conjunctivitis is a hypersensitivity reaction as a part of allergic rhinitis (hay fever), or it can be an independent allergic reaction. The patient usually has a history of an allergy to pollens and other environmental allergens. There is extreme itching, epiphora (ie, excessive secretion of tears), injection, and usually severe photophobia. The stringlike mucoid discharge is usually associated with rubbing the eyes because of severe itching. Vernal conjunctivitis is also known as seasonal conjunctivitis because it appears mostly during warm weather. There may be large formations of papillae that have a cobblestone appearance. It is more common in children and young adults. Most affected individuals have a history of asthma or eczema. TOXIC CONJUNCTIVITIS Chemical conjunctivitis can be the result of medications, chlorine from swimming pools (more common during the summer), exposure to toxic fumes among industrial workers, or exposure to other irritants such as smoke, hair sprays, acids, and alkalis.
Management
FIGURE 58-18
Conjunctival hyperemia in viral conjunctivitis.
The management of conjunctivitis depends on the type. Most types of mild and viral conjunctivitis are self-limiting, benign conditions that may not require treatment and laboratory procedures. For more severe cases, topical antibiotics, eye drops, or ointment are prescribed. Patients with gonococcal conjunctivitis require urgent antibiotic therapy. If left untreated, this ocular disease can lead to corneal perforation and blindness. The systemic complications can include meningitis and generalized septicemia. Acute bacterial conjunctivitis is almost always self-limiting. If left untreated, the disease follows a 2-week course with resolution of symptoms. If treated with appropriate antibiotics, it may last for a few days, with the exception of gonococcal and staphylococcal conjunctivitis. Viral conjunctivitis is not responsive to any treatment. Cold compresses may alleviate some symptoms. It is
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extremely important to remember that viral conjunctivitis, especially EKC, is highly transmissible. Patients must be made aware of the contagious nature of the disease, and adequate instructions must be given. These instructions should include an emphasis on handwashing and avoiding sharing hand towels, face cloths, and eye drops. Tissues should be directly discarded into a trashcan. Proper steps must be taken to avoid nosocomial infections. Frequent hand hygiene, procedures for environmental cleaning, and disinfection of equipment used for eye examination must be strictly followed at all times (Chart 58-9). During outbreaks of conjunctivitis caused by adenovirus, it is necessary that health care facilities assign specified areas for treating patients with or suspected of having conjunctivitis caused by adenovirus to prevent spread. All forms of tonometry must be avoided unless medically indicated. All multidose medications must be discarded at the end of each day or when contaminated. Infected employees and others must not be allowed to work or attend school until symptoms have resolved, which can take 3 to 7 days. Patients with allergic conjunctivitis, especially recurrent vernal or seasonal conjunctivitis, are usually given corticosteroids in ophthalmic preparations. Depending on the severity of the disease, they may be given oral preparations. Use of vasoconstrictors, such as topical epinephrine solution, cold compresses, ice packs, and cool ventilation usually provide comfort by decreasing swelling.
Chart 58-9
• PATIENT EDUCATION Instructions for Patients With Viral Conjunctivitis Viral conjunctivitis is a highly contagious eye infection. It can easily spread from one person to another. The symptoms can be alarming, but they are not serious. The following information will help you understand this eye condition and how to take care of yourself and/or your family member at home. • Your eyes will look red and will have watery discharge, and your lids will be swollen for about a week. • You will experience eye pain, a sandy sensation in your eye, and sensitivity to light. • Symptoms will resolve after about 1 week. • You may use light cold compresses over your eyes for about 10 minutes four to five times a day to soothe the pain. • You may use artificial tears for the sandy sensation in your eye and mild pain medications such as acetaminophen (Tylenol). • You need to stay at home. Children must not play outside. You may return to work or school after 7 days when the redness and discharge have cleared. You may obtain a doctor’s note to return to work or school. • Do not share towels, linens, makeup, or toys. • Wash your hands thoroughly with soap and water frequently, including and before and after you apply artificial tears or cold compresses. • Use a new tissue every time you wipe the discharge from your eye. You may dampen the tissue with clean water to clean the outside of the eye. • You may wash your face and take a shower as you normally do. • Discard all of your makeup articles. You must not apply makeup until the disease is over. • You may wear dark glasses if bright lights bother you. • If the discharge from your eye turns yellowish and puslike or you experience changes in your vision, you need to return to the health care provider for an examination.
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For trachoma, treatment is usually broad-spectrum antibiotics administered topically and systemically. Surgical management includes the correction of trichiasis to prevent conjunctival scarring. Adult inclusion conjunctivitis requires a 1-week course of antibiotics. Prevention of reinfection is important, and affected individuals and their sexual partners must be advised to seek assessment and treatment for sexually transmitted disease, if indicated. For conjunctivitis caused by chemical irritants, the eye must be irrigated immediately and profusely with saline or sterile water.
UVEITIS Inflammation of the uveal tract is called uveitis and can affect the iris, the ciliary body, or the choroid. There are two types of uveitis: nongranulomatous and granulomatous. The most common type of uveitis is the nongranulomatous type, which manifests as an acute condition with pain, photophobia, and a pattern of conjunctival injection, especially around the cornea. The pupil is small or irregular, and vision is blurred. There may be small, fine precipitates on the posterior corneal surface and cells in the aqueous humor (ie, cell and flare). If severe, a hypopyon (ie, accumulation of pus in the anterior chamber) may occur. The condition may be unilateral or bilateral and may be recurrent. Repeated attacks of nongranulomatous anterior uveitis can cause anterior synechia (ie, peripheral iris adheres to the cornea and impedes outflow of aqueous humor). The development of posterior synechia (ie, adherence of the iris and lens) blocks aqueous outflow from the posterior chamber. Secondary glaucoma can result from either anterior or posterior synechia. Cataracts may also occur as a sequela to uveitis. Granulomatous uveitis can have a more insidious onset and can involve any portion of the uveal tract. It tends to be chronic. Symptoms such as photophobia and pain may be minimal. The keratic precipitate may be large and grayish. Vision is markedly and adversely affected. Conjunctival injection is diffuse, and there may be vitreous clouding. In a severe posterior uveitis, such as chorioretinitis, there may be retinal and choroidal hemorrhages.
Management Because photophobia is a common complaint, patients should wear dark glasses outdoors. Ciliary spasm and synechia are best avoided through mydriasis; cylopentolate (Cyclogyl) and atropine are commonly used. Local corticosteroid drops, such as Pred Forte 1% and Flarex 0.1%, instilled four to six times a day are also used to decrease inflammation. In very severe cases, systemic corticosteroids, as well as intravitreal corticosteroids, may be used. If the uveitis is recurrent, a medical workup should be initiated to discover any underlying causes. This evaluation should include a physical examination, complete systems review, and diagnostic tests, including a complete blood cell count, erythrocyte sedimentation rate, antinuclear antibodies (ANA), VDRL, and Lyme disease titer. Underlying causes include toxoplasmosis, herpes zoster virus, ocular candidiasis, histoplasmosis, herpes simplex virus, tuberculosis, and syphilis.
ORBITAL CELLULITIS Orbital cellulitis is inflammation of the tissues surrounding the eye and may result from bacterial, fungal, or viral inflammatory conditions of contiguous structures, such as the face, oropharynx, dental structures, or intracranial structures. It can also result from
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foreign bodies and from a preexisting ocular infection, such as dacryocystitis and panophthalmitis, or from generalized septicemia. Infection of the sinuses is the most frequent cause. Infection originating in the sinuses can spread easily to the orbit through the thin bony walls and foramina or by means of the interconnecting venous system of the orbit and sinuses. The most common causative organisms are staphylococci and streptococci in adults and H. influenzae in children. The severe intraorbital tension caused by abscess formation and the impairment of optic nerve function in orbital cellulitis can result in permanent visual loss. Because of the orbit’s proximity to the brain, orbital cellulitis can lead to life-threatening complications, such as intracranial abscess and cavernous sinus thrombosis.
Management Immediate administration of high-dose, broad-spectrum, systemic antibiotics is indicated. Cultures and Gram-stained smears are obtained. Monitoring changes in visual acuity, degree of proptosis, central nervous system function (eg, nausea, vomiting, fever, level of consciousness), displacement of the globe, extraocular movements, pupillary signs, and the fundus is extremely important. Consultation with an otolaryngologist is necessary, especially when sinusitis is suspected. In the event of abscess formation or progressive loss of vision, surgical drainage of the abscess or sinus is performed. Sinusotomy and antibiotic irrigation are also performed.
Orbital and Ocular Tumors BENIGN TUMORS OF THE ORBIT Benign tumors can develop from infancy and grow rapidly or slowly and present themselves in later life. Some benign tumors are superficial and are easily identifiable by external presentation, palpation, and x-rays, but some are deep and may require a CT scan for a more thorough and precise diagnosis. There can be a significant proptosis, and visual function may be jeopardized. Benign tumors are masses characterized by the lack of infiltration in the surrounding tissues. Examples are cystic dermoid cysts and mucocele, hemangiomas, lymphangiomas, lacrimal tumors, and neurofibromas.
Management To prevent recurrence, benign masses are excised completely when possible. Sometimes, excision is difficult because of the involvement of some portions of the orbital bones, such as deep dermoid cysts, in which dissection of the bone is required. Subtotal resection may be indicated in deep benign tumors that intertwine with other orbital structures, such as optic nerve meningiomas. Complete removal of the tumor may endanger visual function.
BENIGN TUMORS OF THE EYELIDS Benign tumors include a wide variety of neoplasms and increase in frequency with age. Nevi may be unpigmented at birth and may enlarge and darken in adolescence or may never acquire any pigment at all. Hemangiomas are vascular capillary tumors that may be bright, superficial, strawberry-red lesions (ie, strawberry nevus) or bluish and purplish deeper lesions. Milia are small,
white, slightly elevated cysts of the eyelid that, when in multiples, create a blemish. Xanthelasma are yellowish, lipoid deposits on both lids near the inner angle of the eye that commonly appear as a result of the aging of the skin or a lipid disorder. Molluscum contagiosum lesions are flat, symmetric growths along the lid margin caused by a virus that can result in conjunctivitis and keratitis after debris gets into the conjunctival sac.
Management Treatment of benign congenital lid lesions is rarely indicated, except when visual function is affected. Corticosteroid injection to the hemangioma lesion is usually effective, but surgical excision may be performed. Benign lid lesions usually present aesthetic problems rather than visual function problems. Surgical excision, or electrocautery, is primarily performed for cosmetic reasons, except for cases of molluscum contagiosum, for which surgical intervention is performed to prevent an infectious process that may ensue.
BENIGN TUMORS OF THE CONJUNCTIVA Conjunctival nevus, a congenital, benign neoplasm, is a flat, slightly elevated, brown spot that becomes pigmented during late childhood or adolescence. This should be differentiated from the pigmented lesion melanosis acquired at middle age, which tends to wax and wane and become malignant melanoma. Keratin- and sebum-containing dermoid cysts are congenital and can be found in the conjunctiva. Dermolipoma is a congenital tumor that manifests as a smooth, rounded growth in the conjunctiva near the lateral canthus. Papillomas are usually soft with irregular surfaces and appear on the lid margins. Treatment consists of surgical excision.
MALIGNANT TUMORS OF THE ORBIT Rhabdomyosarcoma is the most common malignant primary orbital tumor in childhood, but it can also develop in elderly persons. The symptoms of rhabdomyosarcoma include sudden painless proptosis of one eye followed by lid swelling, conjunctival chemosis, and impairment of ocular motility. Imaging of these tumors establishes the size, configuration, location, and stage of the disease; delineates the degree of bone destruction; and is useful in estimating the field for radiation therapy, if needed. The most common site of metastasis is the lung.
Management Management of these primary malignant orbital tumors involves three major therapeutic modalities: surgery, radiation therapy, and adjuvant chemotherapy. The degree of orbital destruction is important in planning the surgical approach. In the orbit, resection often involves removal of the globe. The psychological needs of the patient and family, especially the parents of a pediatric patient, are paramount in planning the management approach.
MALIGNANT TUMORS OF THE EYELID Basal cell carcinoma is the most common malignant tumor of the eyelid. Squamous cell carcinoma occurs less frequently but is considered the second most common malignant tumor. Malignant melanoma is rare. Malignant eyelid tumors occur more fre-
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quently among people with fair complexion who have a history of chronic exposure to the sun. Basal cell carcinoma appears as a painless nodule that may ulcerate. The lesion is invasive, spreads to the surrounding tissues, and grows slowly but does not metastasize. It usually appears on the lower lid margin near the inner canthus with a pearly white margin. Squamous cell carcinoma of the eyelids may resemble basal cell carcinoma initially because it also grows slowly and painlessly. It tends to ulcerate and invade the surrounding tissues, but it can metastasize to the regional lymph nodes. Malignant melanoma may not be pigmented and can arise from nevi. It spreads to the surrounding tissues and metastasizes to other organs.
Management Complete excision of these carcinomas is followed by reconstruction with skin grafting if the surgical excision is extensive. The ocular postoperative site and the graft donor site are monitored for bleeding. Donor graft sites may include the buccal mucosa, the thigh, or the abdomen. The patient is referred to an oncologist for evaluation for the need for radiation therapy treatment and monitoring for metastasis. Early diagnosis and surgical management are the basis of a good prognosis. These conditions have life-threatening consequences, and surgical excisions may result in facial disfigurement. Emotional support and reassurance are important aspects of nursing management.
MALIGNANT TUMORS OF THE CONJUNCTIVA Conjunctival carcinoma most often grows in the exposed areas of the conjunctiva. The typical lesions are usually gelatinous and whitish due to keratin formation. They grow gradually, and deep invasion and metastasis are rare. Malignant melanoma is rare but may arise from a preexisting nevus or acquired melanosis during middle age. Squamous cell carcinoma is also rare but invasive.
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Management The management is surgical incision. Some benign tumors and most malignant tumors recur. To avoid recurrences, patients usually undergo radiation therapy and cryotherapy after the excision of malignant tumors. Cosmetic disfigurement may result from extensive excision when deep invasion by the malignant tumor is involved.
MALIGNANT TUMOR OF THE GLOBE: OCULAR MELANOMA A malignant tumor of the retina, retinoblastoma, occurs in childhood, is hereditary, and requires complete enucleation if there is to be a chance for successful outcome. Another cancer that primarily occurs in adults is ocular melanoma. This rare, malignant choroidal tumor is often discovered on a retinal examination. In its early stages, it could be mistaken for a nevus. Many ophthalmologists may practice for decades and never encounter this lesion. For this reason, any patient who is suspected of having ocular melanoma should be immediately referred to an ocular oncologist with experience in this disease. Although many patients do not have symptoms in the early stages, some patients complain of blurred vision or a change in eye color. A number of such tumors have been found in people with blindness who have painful eyes. In addition to a complete physical examination to discover any evidence of metastasis (to the liver, lung, and breast), retinal fundus photography, fluorescein angiography, and ultrasonography are performed. The diagnosis is confirmed at biopsy after enucleation.
Management Tumors are classified according to size (ie, small, medium, and large). Very small tumors are generally monitored, whereas medium and large tumors require treatment. Treatment consists of radiation, enucleation, or both. Radiation therapy is achieved by external beam performed in repeated doses over several days or
GENETICS IN NURSING PRACTICE—Genes and the Eye The mapping of the human genome enhances the opportunity to understand the genetic component of ophthalmic disorders and to develop new methods of prevention and treatment. Apparently more than one gene is involved in any particular condition, making genetic counseling an important part of the care and prevention of inherited diseases. Ocular effects of some genetic conditions follow. MARFAN’S SYNDROME Ophthalmic consequences may include amblyopia and dislocation of the lens. Patients are often myopic and may be at increased risk for retinal detachment. LEBER’S CONGENITAL AMAUROSIS To date, four genes are implicated in this disorder, which is characterized by decreased vision and onset in childhood, generally before 7 years of age. It accounts for 10% to 18% of congenital
blindness (some infants may be blind from birth). Other signs and symptoms include strabismus, nystagmus, photophobia, cataracts, and keratoconus. RETINOBLASTOMA A malignant retinal tumor occurring in 1 of every 15,000 live births, it is hereditary in 30% to 40% of cases. All bilateral cases are hereditary. The retinoblastoma gene is found on chromosome 13, region q14. If this gene is inhibited, the growth in retinal cells is unchecked and the retinoblastoma results. Signs and symptoms include an initial leukocoria or “white” pupil with a peculiar light reflection and possibly strabismus as well. Less frequent signs are uveitis, glaucoma, hyphema, nystagmus, and periorbital cellulitis. Treatment for this life-threatening tumor is enucleation, if the tumor is large and unilateral. If the eye is removed before cancer spreads to the optic nerve, the cure rate is greater than 90%.
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through the surgical implantation of a radioactive plaque, which is removed after several days.
Surgical Procedures and Enucleation ORBITAL SURGERIES Orbital surgeries may be performed to repair fractures, remove a foreign body, or remove benign or malignant growths. Surgical procedures involving the orbit and lids affect facial appearance (ie, cosmesis). The goals are to recover and preserve visual function and to maintain the anatomic relationship of the ocular structures to achieve cosmesis. During the repair of orbital fractures, the orbital bones are realigned to follow the anatomic positions of facial structures. Orbital surgical procedures involve working around delicate structures of the eye, such as the optic nerve, retinal blood vessels, and ocular muscles. Complications of orbital surgical procedures may include blindness as a result of damage to the optic nerve and its blood supply. Sudden pain and loss of vision may indicate intraorbital hemorrhage or compression of the optic nerve. Ptosis and diplopia may result from trauma to the extraocular muscles during the surgical procedure, but these conditions typically resolve after a few weeks.
cornea are left intact. The main advantage of evisceration over enucleation is that the final cosmetic result and motility after fitting the ocular prosthesis are enhanced. This procedure would be more acceptable to a patient whose concept of the alteration of body image is severely threatened. The main disadvantage is the high risk of sympathetic ophthalmia. Exenteration is the removal of the eyelids, the eye, and various amounts of orbital contents. It is indicated in malignancies in the orbit that are life threatening or when more conservative modalities of treatment have failed or are inappropriate. An example is squamous cell carcinoma of the paranasal sinuses, skin, and conjunctiva with deep orbital involvement. In its most extensive form, exenteration may include the removal of all orbital tissues and resection of the orbital bones.
Ocular Prostheses
ENUCLEATION
Orbital implants and conformers (ie, ocular prostheses usually made of silicone rubber) maintain the shape of the eye after enucleation or evisceration to prevent a contracted sunken appearance. The temporary conformer is placed over the conjunctival closure after the implantation of an orbital implant. A conformer is placed after the enucleation or evisceration procedure to protect the suture line, maintain the fornices, prevent contracture of the socket in preparation for the ocular prosthesis, and promote the integrity of the eyelids. All ocular prosthetics have limitations in their motility. There are two designs of eye prostheses. The anophthalmic ocular prostheses are used in the absence of the globe. Scleral shells look just like the anophthalmic prosthesis (Fig. 58-19) but are thinner and fit over a globe with intact corneal sensation. An eye prosthesis usually lasts about 6 years, depending on the quality of fit, comfort, and cosmetic appearance. When the anophthalmic socket is completely healed, conformers are replaced with prosthetic eyes. An ocularist is a specially trained and skilled professional who makes prosthetic eyes. After the ophthalmologist is satisfied that the anophthalmic socket is completely healed and is ready for prosthetic fitting, the patient is referred to an ocularist. The healing period is usually 6 to 8 weeks. It is advisable for the patient to have a consultation with the ocularist before the fitting. Obtaining accurate information and verbalizing concerns can lessen anxiety about wearing an ocular prosthesis.
Enucleation is the removal of the entire eye and part of the optic nerve. It may be performed for the following conditions:
Medical Management
Postoperative Management Prophylaxis with intravenous antibiotics is the usual postoperative regimen after orbital surgery, especially with repair of orbital fractures and intraorbital foreign body removal. Intravenous corticosteroids are used if there is a concern about optic nerve swelling. Topical ocular antibiotics are typically instilled, and antibiotic ointments are applied externally to the skin suture sites. For the first 24 to 48 hours postoperatively, ice compresses are applied over the periocular area to decrease periorbital swelling, facial swelling, and hematoma. The head of the patient’s bed should be elevated to a comfortable position (30 to 45 degrees). Discharge teaching should include medication instructions for oral antibiotics, instillation of ophthalmic medications, and application of ocular compresses.
• Severe injury resulting in prolapse of uveal tissue or loss of • • •
light projection or perception An irritated, blind, painful, deformed, or disfigured eye, usually caused by glaucoma, retinal detachment, or chronic inflammation An eye without useful vision that is producing or has produced sympathetic ophthalmia in the other eye Intraocular tumors that are untreatable by other means
The procedure for enucleation involves the separation and cutting of each of the ocular muscles, dissection of the Tenon’s capsule (ie, fibrous membrane covering the sclera), and the cutting of the optic nerve from the eyeball. The insertion of an orbital implant typically follows, and the conjunctiva is closed. A large pressure dressing is applied over the area. Evisceration involves the surgical removal of the intraocular contents through an incision or opening in the cornea or sclera. The optic nerve, sclera, extraocular muscles, and sometimes, the
Removal of an eye has physical, social, and psychological ramifications for any person. The significance of loss of the eye and vision must be addressed in the plan of care. The patient’s preparation should include information about the surgical procedure and placement of orbital implants and conformers and the availability of ocular prosthetics to enhance cosmetic appearance. In some cases, patients may choose to see an ocularist before the surgery to discuss ocular prosthetics.
Nursing Management TEACHING ABOUT POSTSURGICAL AND PROSTHETIC CARE Patients who undergo eye removal need to know that they will usually have a large ocular pressure dressing, which is typically removed after a week, and that an ophthalmic topical antibiotic ointment is applied in the socket three times daily.
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FIGURE 58-19
Eye prostheses. (Left ) Anophthalmic ocular prosthesis. (Right) Scleral shell.
After the removal of an eye, there is a loss of depth perception. Patients must be advised to take extra caution in their ambulation and movement to avoid miscalculations that may result in injury. It may take some time to adjust to monocular vision. The patient must be advised that conformers may accidentally fall out of the socket. If this happens, the conformer must be washed, wiped dry, and placed back in the socket. When surgical eye removal is unexpected, such as in severe ocular trauma, leaving no time for the patient and family to prepare for the loss, the nurse’s role in providing reassurance and emotional support is crucial. PROMOTING HOME AND COMMUNITY-BASED CARE Teaching Patients Self-Care. Patients need to be taught how to insert, remove, and care for the prosthetic eye. Proper hand washing must be observed before inserting and removing an ocular prosthesis. A suction cup may be used if there are problems with manual dexterity. Precautions, such as draping a towel over the sink and closing the sink drain, must be taken to avoid loss of the prosthesis. When instructing patients or family members, a return demonstration is important to assess the level of understanding and ability to perform the procedure. Before insertion, the inner punctal or outer lateral aspects and the superior and inferior aspects of the prosthesis must be identified by locating the identifying marks, such as a reddish color in the inner punctal area. For people with low vision, other forms of identifying markers, such as dots or notches, are used. The upper lid is raised high enough to create a space; then the patient learns to slide the prosthesis up, underneath, and behind the upper eyelid. Meanwhile, the patient pulls the lower eyelid down to help put the prosthesis in place and to have its inferior edge fall back gradually to the lower eyelid. The lower eyelid is checked for correct positioning. To remove the prosthesis, the patient cups one hand on the cheek to catch the prosthesis, places the forefinger of the free hand against the midportion of the lower eyelid, and gazes upward. Gazing upward brings the inferior edge of the prosthesis nearer the inferior eyelid margin. With the finger pushing inward, downward, and laterally against the lower eyelid, the prosthesis slides out, and the cupped hand acts as the receptacle. Continuing Care. An eye prosthesis can be worn and left in place for several months. Hygiene and comfort are usually maintained with daily irrigation of the prosthesis in place with the use of a
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balanced salt solution, hard contact lens solution, or artificial tears. In the case of dry eye symptoms, the use of ophthalmic ointment lubricants or oil-based drops, such as vitamin E and mineral oil, can be helpful. Removing crusting and mucous discharge that accumulates overnight is performed with the prosthesis in place. Malpositions may occur when wiping or rubbing the prosthesis in the socket. The prosthesis can be turned back in place with the use of clean fingers. Proper wiping of the prosthesis should be a gentle temporal-to-nasal motion to avoid malpositions. The prosthesis needs to be removed and cleaned when it becomes uncomfortable and when there is increased mucous discharge. The socket should also be rendered free of mucus and inspected for any signs of infection. Any unusual discomfort, irritation, or redness of the globe or eyelids may indicate excessive wear, debris under the shell, or lack of proper hygiene. Any infection or irritation that does not subside needs medical attention.
Ocular Consequences of Systemic Disease DIABETIC RETINOPATHY Of all of the medical disorders that the nurse encounters, diabetes mellitus is one of the most common and one that can have devastating effects on the patient. Diabetes affects every system of the body in a deleterious way and consequently affects the patient’s family and society in general. Diabetes is the leading cause of new cases of blindness in people between 20 and 74 years of age in the United States today. Before the discovery of insulin in the 1920s, diabetic retinopathy was relatively rare. Most people with diabetes did not survive for more than 1 or 2 years; however, with the use of insulin, more and more patients are able to survive and enjoy relatively normal life spans. They are also confronted with the complications of long-term diabetes. One of the most serious complications is retinopathy. Chapter 41 provides a detailed discussion of diabetic retinopathy (Aiello et al., 2001).
CYTOMEGALOVIRUS RETINITIS Many ophthalmic complications are associated with AIDS. On autopsy, up to 90% of patients have ocular lesions directly related to AIDS. Cytomegalovirus (CMV) is the most common cause of retinal inflammation in patients with AIDS. About 40% of patients who have CMV retinitis lose their central vision in both eyes by the time of death. Early symptoms of CMV retinitis vary from patient to patient. Some patients complain of floaters or a decrease in peripheral vision. Some patients have a paracentral or central scotoma, whereas others have a fluctuation in vision from macular edema. The retina often becomes thin and atrophic and susceptible to retinal tears and breaks. CMV retinitis generally takes one of three forms: hemorrhagic, brushfire, or granular. In the hemorrhagic type, large areas of white, necrotic retina may be associated retinal hemorrhage. The brushfire form appears to have a yellow-white margin, which begins at the edge of burned-out atrophic retina. This retinitis expands and, if untreated, involves the entire retina. The granular form of CMV retinitis consists of white, granular lesions in the periphery of the retina that gradually expand. The white, feathery infiltration of the retina destroys sensory retina and leads to necrosis, optic atrophy, and retinal detachment.
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Medical Management PHARMACOLOGIC THERAPY Pharmacologic agents available for treatment of CMV retinitis include ganciclovir (Cytovene), foscarnet (Foscavir), and cidofovir (Vistide). Ganciclovir is administered intravenously, orally, or intravitreously in the acute stage of CMV retinitis. A surgically implanted intraocular device has provided a new mode of effective ganciclovir administration. This enables a higher, more effective dose of medication to be administered and is well tolerated by patients. This constant intraocular concentration of ganciclovir lasts for about 6 to 10 months before the inserts must be replaced. Once begun, ganciclovir must be given continuously. A study that combined the use of the intravitreous implant with oral ganciclovir demonstrated a reduction in the risk of new CMV disease as well as a delay in the progression of the retinitis (Martin et al., 1999). This very potent medication, when administered systemically, can cause neutropenia, thrombocytopenia, anemia, and elevated serum creatinine levels. Although the surgically implanted sustained release device enables higher concentrations of ganciclovir to reach the CMV retinitis, there are risks and complications associated with the devices, including endophthalmitis, retinal detachment, and hypotony. Foscarnet inhibits viral DNA replication. It may be the medication of choice when ganciclovir is ineffective. It may be administered intravenously or locally by intravitreal injections. The combination of foscarnet and ganciclovir has been more effective than either medication alone. Nephrotoxicity may occur with systemic foscarnet, and renal function must be monitored carefully. Cidofovir impedes CMV replication. This medication is administered intravenously. Cidofovir has been shown to delay the progression of CMV retinitis significantly. Nephrotoxicity, proteinuria, and increased serum creatinine levels are significant side effects of its administration.
HYPERTENSION-RELATED EYE CHANGES Hypertension, known as the silent killer, can shorten the life span by as many as 20 years. End-organ damage affects the heart, brain, kidney, and eye. Hypertension may be manifested in one of two forms: chronic or acute. This differentiation is determined by the rapidity in rise of the blood pressure as well as the degree of elevation. The retinal changes observed with each form are different and have different consequences for the eye. Chronic hypertension and atherosclerosis go hand in hand, and the associated retinal changes are evidenced by the development of retinal arteriolar changes, such as tortuousness, narrowing, and a change in light reflex. Funduscopic examination reveals a copper or silver coloration of the arterioles and venous compression (arteriovenous nicking) at the arteriolar and venous crossings. Intraretinal hemorrhages from hypertension appear flame shaped because they occur in the nerve fiber layer of the retina. Acute hypertension can result from pheochromocytoma, acute renal failure, pregnancy-induced hypertension, and malignant essential hypertension. The retinopathy associated with these crisis states is extensive, and the manifestations include cotton-wool spots, retinal hemorrhages, retinal edema, and retinal exudates, often clustered around the macula. The choroid is also affected by the profound and abrupt rise in blood pressure and resulting vasoconstriction, and ischemia may result in serous retinal detachments and infarction of the
retinal pigment epithelium (RPE). Ischemic optic neuropathy and papilledema (ie, swelling of the optic disc due to increased IOP) may also result.
Concepts in Ocular Medication Administration The main objective of ocular medication delivery is to maximize the amount of medication that reaches the ocular site of action in sufficient concentration to produce a beneficial therapeutic effect. This is determined by the dynamics of ocular pharmacokinetics: absorption, distribution, metabolism, and excretion. Topical administration of ocular medications results in only a 1% to 7% absorption rate by the ocular tissues. Ocular absorption involves the entry of a medication into the aqueous humor through the different routes of ocular drug administration. The rate and extent of aqueous humor absorption are determined by the characteristics of the medication and the barriers imposed by the anatomy and physiology of the eye. The natural barriers of absorption that diminish the efficacy of ocular medications include the following:
• Limited size of the conjunctival sac. The conjunctival sac can
• •
•
hold only 50 µL, and any excess is wasted. The volume of one eye drop from commercial topical ocular solutions typically ranges from 20 to 35 µL. Corneal membrane barriers. The epithelial, stromal, and endothelial layers are barriers to absorption. Blood–ocular barriers. Blood–ocular barriers prevent high ocular tissue concentration of most ophthalmic medications because they separate the bloodstream from the ocular tissues and keep foreign substances from entering the eye, thereby limiting a medication’s efficacy. Tearing, blinking, and drainage. Increased tear production and drainage due to ocular irritation or an ocular condition may dilute or wash out an instilled eye drop; blinking expels an instilled eye drop from the conjunctival sac.
Distribution of an ocular medication into the ocular tissues involves partitioning and compartmentalizing of the medication between the tissues of the conjunctiva, cornea, lens, iris, ciliary body, choroid, and vitreous. Medications penetrate the corneal epithelium by diffusion by passing through the cells (intracellular) or by passing between the cells (intercellular). Water-soluble (hydrophilic) medications diffuse through the intracellular route, and fat-soluble (lipophilic) medications diffuse through the intercellular route. Topical administration usually does not reach the retina in significant concentrations. Because the space between the ciliary process and the lens is small, medication diffusion in the vitreous is slow. When high therapeutic medication concentration in the vitreous is required, intraocular injection is often chosen to bypass the natural ocular anatomic and physiologic barriers. Aqueous solutions are most commonly used for the eye. They are the least expensive medications and interfere least with vision. However, corneal contact time is brief because tears dilute the medication. Ophthalmic ointments have extended retention time in the conjunctival sac and a higher concentration than eye drops. The major disadvantage of ointments is the blurred vision that results after application. In general, eyelids and eyelid margins are best treated with ointments. The conjunctiva, limbus, cornea, and anterior chamber are treated most effectively with instilled solutions or suspensions. Subconjunctival injection may be necessary for better absorption in the anterior chamber. If high med-
Chapter 58
Assessment and Management of Patients With Eye and Vision Disorders
ication concentrations are required in the posterior chamber, intravitreal injections or systemically absorbed medications are considered. Contact lenses and collagen shields soaked in antibiotics are alternative delivery methods for treating corneal infections. Of all these delivery methods, the topical route of administration—instilled eye drops and applied ointments—remain the most common. Topical instillation, which is the least invasive method, permits self-administration of medication. It also produces fewer side effects. Preservatives are commonly used in ocular medications. Benzalkonium chloride, for example, prevents the growth of organisms and enhances the corneal permeability of most medications. Some patients are allergic to this preservative. This may be suspected even if the patient had never before experienced an allergic reaction to systemic use of the medication in question. Eye drops without preservatives can be prepared by pharmacists.
COMMONLY USED OCULAR MEDICATIONS Common ocular medications include topical anesthetic, mydriatic, and cycloplegic agents that reduce IOP; anti-infective medications, corticosteroids, NSAIDS, antiallergy medications, eye irrigants, and lubricants.
Topical Anesthetics One to two drops of proparacaine hydrochloride (Ophthaine 0.5%) and tetracaine hydrochloride (Pontocaine 0.5%) are instilled before diagnostic procedures such as tonometry and gonioscopy and in minor ocular procedures such as removal of sutures or conjunctival or corneal scrapings. The nurse must instruct patients not to rub their eyes while anesthetized because this may result in corneal damage. Patients must never be allowed to take topical anesthetics home. Prolonged use can delay wound healing and
Table 58-8 DRUG
AVAILABLE PREPARATION/ CONCENTRATION
Solutions (2.5%, 10%)
Atropine
Ointment (0.5%–2%) Solutions (0.5%–3%) Solution (0.25%) Solution (5%–2.5%) Solution (0.5%–2%) Solution (0.25%–1%)
Homatropine Cyclopentolate Tropicamide
can lead to permanent corneal opacification and scarring, resulting in visual loss. Topical anesthetic is also used for severe eye pain to allow the patient to open his or her eyes for examination or treatment (eg, eye irrigation for chemical burns). Anesthesia occurs within 20 seconds to 1 minute and lasts 10 to 20 minutes.
Mydriatics and Cycloplegics Mydriasis, or pupil dilation, is the main objective of the administration of mydriatic and cycloplegic agents (Table 58-8). These two medications function differently and are used in combination to achieve the maximal dilation that is needed during surgery and fundus examinations to give the ophthalmologist a better view of the internal eye structures. Mydriatics potentiate alpha-adrenergic sympathetic effects that result in the relaxation of the ciliary muscle. This causes the pupil to dilate. This sympathetic action alone, however, is not enough to sustain mydriasis because of its short duration of action. The strong light used during an eye examination also stimulates miosis (ie, pupillary contraction). Cycloplegic medications are administered to paralyze the iris sphincter. Patients are instructed about the temporary effects of mydriasis on vision, such as glare and the inability to focus properly. Patients may not be able to read and should not drive. The effects of the various mydriatics and cycloplegics can last 3 hours to several days. Patients are advised to wear sunglasses (most eye clinics provide protective sunglasses) and to have a responsible adult drive them home. Mydriatic and cycloplegic agents affect the central nervous system. Their effects are most prominent in children and elderly patients; these patients must be assessed closely for symptoms, such as rise in blood pressure, tachycardia, dizziness, ataxia, confusion, disorientation, incoherent speech, and hallucination. These medications are contraindicated in patients with narrow
• Mydriatics and Cycloplegics
Phenylephrine
Scopolamine
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RECOVERY TIME
INDICATION/DOSAGE
Mydriasis
Administered with cycloplegics in pupillary dilation for ophthalmoscopy and surgical procedures every 5–10 min ×3 or until the pupils are fully dilated In glaucoma, uveitis, or after surgery, 2× to 4× daily
10–60 min
—
3–6 h
30–40 min
60–180 min
7–10 d
6–12 d
The same as atropine
20–30 min
30–60 min
3–7 d
3–7 d
The same as atropine and scopolamine Administered with mydriatics q 5–10 min ×3 or until the pupils are fully dilated for ophthalmoscopy and surgical procedures
40–60 min
30–60 min
1–3 d
1–3 d
30–60 min
25–75 min
1d
6–24 h
20–40 min
20–35 min
6h
15–25 >25–40 >40–55 >55–70 >70–90 >90
Normal hearing Slight hearing loss Mild hearing loss Moderate hearing loss Moderate to severe hearing loss Severe hearing loss Profound hearing loss
Chapter 59
Assessment and Management of Patients With Hearing and Balance Disorders
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Hearing Loss
SPEECH HEARING TESTS TEST
R
L
BIN
Sp. Reception Threshold (SRT)
10 db
10 db
Sp. Discrim. Scores
80 db HL
100%
100%
%
%
(PB)
db HL
%
%
%
%
db HL
%
%
%
%
db
SF db
FIGURE 59-7 The speech reception threshold is the sound intensity level at which a patient is just capable of correctly identifying simple speech stimuli. Speech discrimination determines the patient’s ability to distinguish different sounds, in the form of words, at a decibel level where sound is heard. It is also used to assess the oculomotor and vestibular systems and their corresponding interaction. It helps in diagnosing conditions such as Ménière’s disease and tumors of the internal auditory canal or posterior fossa. Any vestibular suppressants, such as sedatives, tranquilizers, antihistamines, and alcohol are withheld for 24 hours before testing. Prior to the test the procedure is explained to the patient.
PLATFORM POSTUROGRAPHY Platform posturography is used to investigate postural control capabilities. The integration of visual, vestibular, and proprioceptive cues (ie, sensory integration) with motor response output and coordination of the lower limbs is tested. The patient stands on a platform, surrounded by a screen, and different conditions such as a moving platform with a moving screen or a stationary platform with a moving screen are presented. The responses from the patient on six different conditions are measured and indicate which of the anatomic systems may be impaired. Preparation for the testing is the same as for electronystagmography.
SINUSOIDAL HARMONIC ACCELERATION Sinusoidal harmonic acceleration, or a rotary chair, is used to assess the vestibulo-ocular system by analyzing compensatory eye movements in response to the clockwise and counterclockwise rotation of the chair. Although such testing cannot identify the side of the lesion in unilateral disease, it helps identify disease and evaluate the course of recovery. The same patient preparation is required as for electronystagmography.
MIDDLE EAR ENDOSCOPY With endoscopes with very small diameters and acute angles, the ear can be examined endoscopically by an endoscopist specializing in otolaryngology. Middle ear endoscopy is performed safely and effectively as an office procedure to evaluate suspected perilymphatic fistula and new-onset conductive hearing loss, the anatomy of the round window before transtympanic treatment of Ménière’s disease, and the tympanic cavity before ear surgery to treat chronic middle ear and mastoid infections. The tympanic membrane is anesthetized topically for about 10 minutes. Then, the external auditory canal is irrigated with sterile normal saline solution. With the aid of a microscope, a tympanotomy is created with a laser beam or a myringotomy knife, so that the endoscope can be inserted into the middle ear cavity. Video and photo documentation can be accomplished through the scope.
More than 26 million people in the United States have some form of hearing impairment (Larson et. al., 2000). Most can be helped with medical or surgical therapies or with a hearing aid. By the year 2050, about one of every five people in the United States, or almost 58 million people, will be 55 years of age or older. Of this population, almost one half can expect a hearing impairment (U.S. Public Health Service, 2000). Approximately 10 million persons in the United States have irreversible hearing loss (National Strategic Research Plan of the National Institute on Deafness and Other Communication Disorders [NIDCD], 1998). It is estimated that more than 30 million people are exposed to noise levels that produce hearing loss on a daily basis. Occupations such as carpentry, plumbing, and coal mining have the highest risk of noise-induced hearing loss. Researchers report greater than 90% of coal miners are estimated to have hearing loss by the age of 52 years (Franks, 1996). Conductive hearing loss usually results from an external ear disorder, such as impacted cerumen, or a middle ear disorder, such as otitis media or otosclerosis. In such instances, the efficient transmission of sound by air to the inner ear is interrupted. A sensorineural loss involves damage to the cochlea or vestibulocochlear nerve. Mixed hearing loss and functional hearing loss also may occur. The patient with mixed hearing loss has conductive loss and sensorineural loss, resulting from dysfunction of air and bone conduction. A functional (or psychogenic) hearing loss is nonorganic and unrelated to detectable structural changes in the hearing mechanisms; it is usually a manifestation of an emotional disturbance.
Clinical Manifestations Early manifestations of hearing impairment and loss may include tinnitus, increasing inability to hear in groups, and a need to turn up the volume of the television. Hearing impairment can also trigger changes in attitude, the ability to communicate, the awareness of surroundings, and even the ability to protect oneself, affecting the person’s quality of life. In a classroom, a student with impaired hearing may be disinterested and inattentive and have failing grades. A person at home may feel isolated because of an inability to hear the clock chime, the refrigerator hum, the birds sing, or the traffic pass. A hearing-impaired pedestrian may attempt to cross the street and fail to hear an approaching car. Hearing-impaired people may miss parts of a conversation. Many people are unaware of their gradual hearing impairment. Often, it is not the person with the hearing loss, but the people with whom he or she is communicating who recognize the impairment first (see Chart 59-2). For various reasons, some people with hearing loss refuse to seek medical attention or wear a hearing aid. Others feel self-conscious wearing a hearing aid. Insightful patients generally ask those with whom they are trying to communicate to let them know whether difficulties in communication exist. These attitudes and behaviors should be taken into account when counseling patients who need hearing assistance. The decision to wear a hearing aid is a personal one that is affected by these attitudes and behaviors.
Prevention Many environmental factors have an adverse effect on the auditory system and, with time, result in permanent sensorineural hearing loss. The most common is noise.
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Chart 59-2
SENSORINEURAL FUNCTION
Chart 59-3
• ASSESSMENT
Risk Factors for Hearing Loss
Symptoms of Hearing Loss Speech deterioration: The person who slurs words or drops word endings, or produces flat-sounding speech, may not be hearing correctly. The ears guide the voice, both in loudness and in pronunciation. Fatigue: If a person tires easily when listening to conversation or to a speech, fatigue may be the result of straining to hear. Under these circumstances, the person may become irritable very easily. Indifference: It is easy for the person who cannot hear what others say to become depressed and disinterested in life in general. Social withdrawal: Not being able to hear what is going on causes the hearing-impaired person to withdraw from situations that might prove embarrassing. Insecurity: Lack of self-confidence and fear of mistakes create a feeling of insecurity in many hearing-impaired people. No one likes to say the wrong thing or do anything that might appear foolish. Indecision and procrastination: Loss of self-confidence makes it increasingly difficult for a hearing-impaired person to make decisions. Suspiciousness: The hearing-impaired person, who often hears only part of what is being said, may suspect that others are talking about him or her, or that portions of the conversation are deliberately spoken softly so that he or she will not hear them. False pride: The hearing-impaired person wants to conceal the hearing loss and thus often pretends to be hearing when he or she actually is not. Loneliness and unhappiness: Although everyone wishes for quiet now and then, enforced silence can be boring and even somewhat frightening. People with a hearing loss often feel isolated. Tendency to dominate the conversation: Many hearing-impaired people tend to dominate the conversation, knowing that as long as it is centered on them and they can control it, they are not so likely to be embarrassed by some mistake.
Noise (ie, unwanted and unavoidable sound) has been identified as one of the environmental hazards of the 20th century. The sheer volume of noise that surrounds us daily has increased from a simple annoyance into a potentially dangerous source of physical and psychological damage. In terms of physical impact, loud, persistent noise has been found to cause constriction of peripheral blood vessels, increased blood pressure and heart rate (because of increased secretion of adrenalin), and increased gastrointestinal activity. Additional research is needed to address the overall effects of noise on the human body. It seems certain, however, that a quiet environment is more conducive to peace of mind. A person who is ill feels more at ease when noise is kept to a minimum. There are numerous factors that contribute to hearing loss (see Chart 59-3). The term noise-induced hearing loss is used to describe hearing loss that follows a long period of exposure to loud noise (eg, heavy machinery, engines, artillery). Acoustic trauma refers to the hearing loss caused by a single exposure to an extremely intense noise, such as an explosion. Usually, noise-induced hearing loss occurs at a high frequency (around 4,000 Hz). However, with continued noise exposure, the hearing loss can become more severe and include adjacent frequencies. The minimum noise level known to cause noise-induced hearing loss, regardless of duration, is about 85 to 90 dB. Noise exposure is inherent in many jobs (eg, mechanics, printers, pilots, musicians) and in hobbies such as woodworking and
• • • • • • • •
Family history of sensorineural impairment Congenital malformations of the cranial structure (ear) Low birth weight (25 lb), straining, and bending over for a few weeks after surgery. • Know that popping and crackling in the operative ear is normal for approximately 3 to 5 weeks after surgery. • Be aware that packing in the operated ear, as well as blood and fluid in the middle ear after surgery, will cause a hearing loss. You may also feel that you are talking in a well or hearing echoes. • Remember that minor ear discomfort is normal; use the analgesics prescribed. Report any excessive ear pain to the surgeon. • Note that some slightly bloody or serosanguineous drainage from the ear is normal after surgery. Report any excessive or purulent ear drainage to the surgeon. • Change the cotton ball in the ear as needed. • Check with the surgeon for instructions regarding air travel. • Avoid getting water in the operated ear for 2 weeks after surgery. You may shampoo the hair 2 to 3 days postoperatively if the ear is protected from water by saturating a cotton ball with petroleum jelly (or some other water-insoluble substance) and loosely placing it in the ear. If the postauricular suture line becomes wet, pat (not rub) the area and cover it with a thin layer of antibiotic ointment.
2. Remains free of discomfort or pain a. Exhibits no facial grimacing, moaning, or crying, and reports absence of pain b. Uses analgesics appropriately 3. Demonstrates no signs or symptoms of infection a. Has normal vital signs, including temperature b. Demonstrates absence of purulent drainage from the external auditory canal c. Describes method for preventing water from contaminating packing 4. Exhibits signs that hearing has stabilized or improved a. Describes surgical goal for hearing and judges whether the goal has been met b. Verbalizes that hearing has improved 5. Remains free of injury and trauma because of vertigo a. Reports absence of vertigo or balance disturbance b. Experiences no injury or fall c. Modifies environment to avoid falls (eg, night light, no clutter on stairs) 6. Adjusts to or remains free from altered sensory perception a. Reports no taste disturbance, mouth dryness, or facial weakness 7. Demonstrates no skin breakdown a. Lists ways to prevent dislodging graft or prosthesis b. Is aware of limitations in activities (eg, bathing, lifting, air travel) and for how long
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8. Verbalizes the reasons for and methods of care and treatment a. Shares knowledge with family about treatment protocol b. Describes treatment and the time frame for the recovery phase c. Discusses the discharge plan formulated with the nurse with regard to rest periods, medication, and activities permitted and restricted d. Lists symptoms that should be reported to health care personnel e. Keeps follow-up appointments
OTOSCLEROSIS Otosclerosis involves the stapes and is thought to result from the formation of new, abnormal spongy bone, especially around the oval window, with resulting fixation of the stapes. The efficient transmission of sound is prevented because the stapes cannot vibrate and carry the sound as conducted from the malleus and incus to the inner ear. More common in women and frequently hereditary, otosclerosis may be worsened by pregnancy.
Clinical Manifestations The condition can involve one or both ears and manifests as a progressive conductive or mixed hearing loss. The patient may or may not complain of tinnitus. Otoscopic examination usually reveals a normal tympanic membrane. Bone conduction is better than air conduction on Rinne testing. The audiogram confirms conductive hearing loss or mixed loss, especially in the low frequencies.
Medical Management There is no known nonsurgical treatment for otosclerosis. However, some physicians believe the use of Florical (a fluoride supplement) can mature the abnormal spongy bone growth. Amplification with a hearing aid also may help. SURGICAL MANAGEMENT A stapedectomy, performed through the canal, involves removing the stapes superstructure and part of the footplate and inserting a tissue graft and a suitable prosthesis (Fig. 59-8). Some surgeons elect to remove only a small part of the stapes footplate (ie, stapedotomy). Regardless of the method used, the prosthesis bridges the gap between the incus and the inner ear, providing better sound conduction. Stapes surgery is very successful in improving hearing. Balance disturbance or true vertigo, which rarely occurs in other middle ear surgical procedures, can occur for a short time after stapedectomy.
MIDDLE EAR MASSES Other than cholesteatoma, masses in the middle ear are rare. Glomus jugulare is a tumor that arises from the jugular bulb. A histologically identical tumor that arises from Jacobson’s nerve and remains limited to the middle ear is known as a glomus tympanicum. On otoscopy, a red blemish on or behind the tympanic membrane is indicative of a glomus tumor. The treatment for glomus tumors is surgical excision, except in poor surgical candidates, in whom radiation therapy is used. A facial nerve neuroma is a tumor on cranial nerve VII, the facial nerve. These types of tumors are usually not visible on otoscopic examination but are suspected when a patient presents with a facial nerve paresis. X-ray evaluation is necessary to determine
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SENSORINEURAL FUNCTION
A
C
B
D
E
FIGURE 59-8
Stapedectomy for otosclerosis. (A) Normal anatomy. (B) Arrow points to sclerotic process at the foot of the stapes. (C) Stapes broken away surgically from its diseased base. The hole in the footplate provides an area where an instrument can grasp the plate. (D) The footplate is removed from its base. Some otosclerotic tissue may remain, and tissue is placed over it. (E) Robinson stainless-steel prosthesis in position.
the site of the tumor along the facial nerve. The treatment is surgical removal. Other less common problems of the middle ear include cholesterin granuloma and tympanosclerosis. Cholesterin granuloma is an immune system reaction to the byproducts of blood (ie, cholesterol crystals) within the middle ear. Tympanosclerosis is a deposit of collagen and minerals within the middle ear that can harden around the ossicles as a result of repeated infections. It can also be found as plaque on the tympanic membrane; this can decrease hearing.
Conditions of the Inner Ear Disorders of balance and the vestibular system involving the inner ear afflict more than 30 million Americans 17 years of age or older. Falls resulting from these disorders account for more than 100,000 hip fractures in elderly people each year (NIDCD, 1998). The term dizziness is used frequently by patients and health care providers to describe any altered sensation of orientation in space. Vertigo is defined as the misperception or illusion of motion of the person or the surroundings. Most people with vertigo describe a spinning sensation or say they feel as though objects are moving around them. Ataxia is a failure of muscular coordination
and may be present in patients with vestibular disease. Syncope, fainting, and loss of consciousness are not forms of vertigo, nor are they characteristic of an ear problem; they usually indicate disease in the cardiovascular system. Nystagmus is an involuntary rhythmic movement of the eyes. Nystagmus occurs normally when a person watches a rapidly moving object (eg, through the side window of a moving car or train). However, pathologically it is an ocular disorder associated with vestibular dysfunction. Nystagmus can be horizontal, vertical, or rotary and can be caused by a disorder in the central or peripheral nervous system.
MOTION SICKNESS Motion sickness is a disturbance of equilibrium caused by constant motion. For example, it can occur aboard a ship, while riding on a merry-go-round or swing, or in the back seat of a car.
Clinical Manifestations The syndrome manifests itself in sweating, pallor, nausea, and vomiting caused by vestibular overstimulation. These manifestations may persist for several hours after the stimulation stops.
Chapter 59
Assessment and Management of Patients With Hearing and Balance Disorders
Management Over-the-counter antihistamines used to treat vertigo, such as dimenhydrinate (Dramamine) or meclizine hydrochloride (Bonine), provide some relief. Anticholinergic medications, such as scopolamine patches, may be helpful. These must be replaced every few days. Side effects such as dry mouth and drowsiness occur with these medications, which may prove to be more troublesome than helpful. Potentially hazardous activities such as driving a car or operating heavy machinery should be avoided if the patient experiences drowsiness.
MÉNIÈRE’S DISEASE Ménière’s disease is an abnormal inner ear fluid balance caused by a malabsorption in the endolymphatic sac. Evidence indicates that many people with Ménière’s disease may have a blockage in the endolymphatic duct. Regardless of the cause, endolymphatic hydrops, a dilation in the endolymphatic space, develops. Either increased pressure in the system or rupture of the inner ear membranes occurs, producing symptoms of Ménière’s disease. Ménière’s disease affects more than 2.4 million people in the United States. More common in adults, it has an average age of onset in the 40s, with symptoms usually beginning between the ages of 20 and 60 years. However, the disease has been reported in children as young as age 4 years and in adults up to the 90s. Ménière’s disease appears to be equally common in both genders. The right and left ears are affected with equal frequency; the disease occurs bilaterally in about 20% of patients. About 20% of the patients have a positive family history for the disease (Knox & McPherson, 1997).
Clinical Manifestations Ménière’s disease involves the following symptoms: fluctuating, progressive sensorineural hearing loss; tinnitus or a roaring sound; a feeling of pressure or fullness in the ear; and episodic, incapacitating vertigo, often accompanied by nausea and vomiting. The effects of these symptoms range from a minor nuisance to extreme disability, especially if the attacks of vertigo are severe. At the onset of the disease, perhaps only one or two of the symptoms are manifested. Some clinicians believe that there are two subsets of the disease, known as atypical Ménière’s disease: cochlear and vestibular. Cochlear Ménière’s disease is recognized as a fluctuating, progressive sensorineural hearing loss associated with tinnitus and aural pressure in the absence of vestibular symptoms or findings. Vestibular Ménière’s disease is characterized as the occurrence of episodic vertigo associated with aural pressure but no cochlear symptoms. In some patients, cochlear or vestibular Ménière’s disease develops first. In most patients, however, all of the symptoms develop eventually.
Assessment and Diagnostic Findings Vertigo is usually the most troublesome complaint. A careful history is taken to determine the frequency, duration, severity, and character of the vertigo attacks. Typically, the patient reports that vertigo lasts minutes to hours, possibly accompanied by nausea or vomiting. Patients also complain of diaphoresis and a persistent feeling of imbalance or disequilibrium, which may last for days. They may complain of attacks that awaken them at night. Between attacks, however, they usually feel well. The hearing loss may fluctuate, with tinnitus and aural pressure waxing and wan-
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ing with changes in hearing. The tinnitus and feeling of aural pressure may occur only during or before attacks, or they may be constant. Findings of the physical examination are usually normal, with the exception of the evaluation of cranial nerve VIII. Sounds from a tuning fork (ie, Weber test) may lateralize to the ear opposite the hearing loss, the one affected with Ménière’s disease. An audiogram typically reveals a sensorineural hearing loss in the affected ear. This can be in the form of a “Pike’s Peak” pattern, which looks like a hill or mountain, or it may show a sensorineural loss in the low frequencies. As the disease progresses, the hearing loss increases. The electronystagmogram may be normal or may show reduced vestibular response. There is, however, no absolute diagnostic test.
Medical Management Most patients with Ménière’s disease can be successfully treated with diet and medication therapy. Many patients can control their symptoms by adhering to a low-sodium (2,000 mg/day) diet. The amount of sodium is one of many factors that regulate the balance of fluid within the body. Sodium and fluid retention disrupts the delicate balance between endolymph and perilymph in the inner ear. Psychological evaluation may be indicated if the patient is anxious, uncertain, fearful, or depressed. PHARMACOLOGIC THERAPY Pharmacologic therapy for Ménière’s disease consists of antihistamines such as meclizine (Antivert), which suppress the vestibular system. Tranquilizers such as diazepam (Valium) may be used in acute instances to help control vertigo. Antiemetics such as promethazine (Phenergan) suppositories help control the nausea and vomiting and the vertigo because of their antihistamine effect. Diuretic therapy (eg, hydrochlorothiazide) sometimes relieves symptoms by lowering the pressure in the endolymphatic system. Intake of foods containing potassium (eg, bananas, tomatoes, oranges) is necessary if the patient takes a diuretic that causes potassium loss. Vasodilators, such as nicotinic acid, papaverine hydrochloride (Pavabid), and methantheline bromide (Banthine), have no scientific basis for alleviating the symptoms, but they are often used in conjunction with other therapies. SURGICAL MANAGEMENT Although most patients respond well to conservative therapy, some continue to have disabling attacks of vertigo. If these attacks reduce their quality of life, patients may elect to undergo surgery for relief. However, hearing loss, tinnitus, and aural fullness may continue, because the surgical treatment of Ménière’s disease is aimed at eliminating the attacks of vertigo. Endolymphatic Sac Decompression. Endolymphatic sac decompression, or shunting, theoretically equalizes the pressure in the endolymphatic space. A shunt or drain is inserted in the endolymphatic sac through a postauricular incision. This procedure is favored by many otolaryngologists as a first-line surgical approach to treat the vertigo of Ménière’s disease because it is relatively simple and safe and can be performed on an outpatient basis. Middle and Inner Ear Perfusion. Ototoxic medications, such as streptomycin or gentamicin, can be given to patients by infusion into the middle and inner ear. These medications are used to decrease vestibular function and decrease vertigo. The success rate
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for eliminating vertigo is high, about 85%, but the risk of significant hearing loss is also high. This procedure of inner ear perfusion usually requires an overnight stay in the hospital. After the procedure, many patients have a period of imbalance that lasts several weeks. Intraotologic Catheters. In an attempt to deliver medication directly to the inner ear, catheters are being developed to provide a conduit from the outer ear to the inner ear. The route of the catheter is from the external ear canal through or around the tympanic membrane and to the round window niche or membrane. Medicinal fluids can be placed against the round window for a direct route to the inner ear fluids. Potential uses of these catheters include treatment for sudden hearing loss and various disorders causing intractable vertigo. Future applications may include tinnitus and slowly progressing sensorineural hearing loss. Intratympanic injections of ototoxic medications for round window membrane diffusion can be used to decrease vestibular function. Established surgical techniques can be used for the patient with vertigo who has not responded to medical or physical therapeutic modalities. Vestibular Nerve Section. Vestibular nerve section provides the greatest success rate (approximately 98%) in eliminating the attacks of vertigo. It can be performed by a translabyrinthine approach (ie, through the hearing mechanism) or in a manner that can conserve hearing (ie, suboccipital or middle cranial fossa), depending on the degree of hearing loss. Most patients with incapacitating Ménière’s disease have little or no effective hearing. Cutting the nerve prevents the brain from receiving input from the semicircular canals. This procedure requires a brief hospital stay. Nursing care for the patient with vertigo is presented in Plan of Nursing Care 59-1.
LABYRINTHITIS Labyrinthitis, an inflammation of the inner ear, can be bacterial or viral in origin. Although rare because of antibiotic therapy, bacterial labyrinthitis usually occurs as a complication of otitis media. The infection can enter the inner ear by penetrating the membranes of the oval or round windows. Viral labyrinthitis is a common medical diagnosis, but little is known about this disorder, which affects hearing and balance. The most commonly identified viral causes are mumps, rubella, rubeola, and influenza. Viral illnesses of the upper respiratory tract and herpetiform disorders of the facial and acoustic nerves (ie, Ramsay Hunt syndrome) also cause labyrinthitis.
Clinical Manifestations Labyrinthitis is characterized by a sudden onset of incapacitating vertigo, usually with nausea and vomiting, various degrees of hearing loss, and possibly tinnitus. The first episode is usually the worst; subsequent attacks, which usually occur over a period of several weeks to months, are less severe.
Management Treatment of bacterial labyrinthitis includes intravenous antibiotic therapy, fluid replacement, and administration of a vestibular suppressant, such as meclizine, and antiemetic medications. Treatment of viral labyrinthitis is tailored to the patient’s symptoms.
BENIGN PAROXYSMAL POSITIONAL VERTIGO Benign paroxysmal positional vertigo (BPPV) is a brief period of incapacitating vertigo that occurs when the position of the patient’s head is changed with respect to gravity, typically by placing the head back with the affected ear turned down. The onset is sudden and followed by a predisposition for positional vertigo, usually for hours to weeks but occasionally for months or years. It is speculated to be caused by the disruption of debris within the semicircular canal. This debris is formed from small crystals of calcium carbonate from the inner ear structure, the utricle. This is frequently stimulated by head trauma, infection, or other events. In severe cases, vertigo may easily be induced by any head movement. The vertigo is usually accompanied by nausea and vomiting; however, hearing impairment does not generally occur (Hain, 2002). Bed rest is recommended for patients with acute symptoms. Canalith repositioning procedures (CRP) may be used to provide resolution of vertigo. The Epley procedure is a repositioning technique that is safe, inexpensive, and easy to perform for these patients. However, this procedure is not recommended for patients with acute vertigo or for patients diagnosed with vestibular neuronitis (a paroxysmal attack of severe vertigo). Patients with acute vertigo may be medicated with meclizine for 1 to 2 weeks. After this time, the meclizine is stopped and the patient is reassessed. Patients who continue to have severe positional vertigo may be premedicated with prochloperazine (Compazine) 1 hour before performing the CRP. The Dix-Hallpike test is used to assess for BPPV. When the Dix-Hallpike test results are positive on the right side, a left-sided CRP is used (Fig. 59-9). Vestibular rehabilitation can be used in the management of vestibular disorders. This strategy promotes active use of the vestibular system through a multidisciplinary team approach, including medical and nursing care, stress management, biofeedback, vocational rehabilitation, and physical therapy. A physical therapist prescribes balance exercises that help the brain compensate for the impairment to the balance system.
OTOTOXICITY A variety of medications may have adverse effects on the cochlea, vestibular apparatus, or cranial nerve VIII. All but a few, such as aspirin and quinine, cause irreversible hearing loss. At high doses, aspirin toxicity also can produce tinnitus. Intravenous medications, especially the aminoglycosides, are the most common cause of ototoxicity, and they destroy the hair cells in the organ of Corti (see Chart 59-6). To prevent loss of hearing or balance, patients receiving potentially ototoxic medications should be counseled about the side effects of these medications. Blood levels of the medications should be monitored and patients receiving long-term intravenous antibiotics should be monitored with an audiogram twice each week during therapy.
ACOUSTIC NEUROMA An acoustic neuroma is a slow-growing, benign tumor of cranial nerve VIII, usually arising from the Schwann cells of the vestibular portion of the nerve. Most acoustic tumors arise within the internal auditory canal and extend into the cerebellopontine angle to press on the brain stem. Acoustic neuromas account for 5% to 10% of all intracranial tumors and seem to occur with equal frequency in men and women at any age, although most occur during (text continues on page 1812)
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Plan of Nursing Care Care of the Patient With Vertigo Nursing Interventions
Rationale
Expected Patient Outcomes
Nursing Diagnosis: Risk for injury related to altered mobility because of gait disturbance and vertigo Goal: Remains free of any injuries associated with imbalance and/or falls 1. Assess for vertigo, including history, onset, description of attacks, duration, frequency, and any associated ear symptoms (hearing loss, tinnitus, aural fullness). 2. Assess extent of disability in relation to activities of daily living. 3. Teach or reinforce vestibular/balance therapy as prescribed. 4. Administer, or teach administration of, antivertiginous medications and/or vestibular sedation medication; instruct patient about side effects. 5. Encourage patient to sit down when dizzy. 6. Place pillow on each side of head to restrict movement. 7. Assist patient in identifying aura that suggests an impending attack. 8. Recommend that the patient keep eyes open and stare straight ahead when lying down and experiencing vertigo.
1. History provides basis for interventions.
2. Extent of disability indicates risk of falling. 3. Exercises hasten labyrinthine compensation, which may decrease vertigo and gait disturbance. 4. Alleviates acute symptoms of vertigo
• Experiences no falls due to balance • • • • • • •
disturbance Fear and anxiety are reduced Performs exercises as prescribed Takes prescribed medications appropriately Assumes safe position when vertigo is present Keeps head still when vertigo is present Identifies a characteristic fullness or sense of pressure in the ear as occurring before a full-blown attack Reports measures that help reduce vertigo
5. Decreases possibility of falling and injury 6. Movement aggravates vertigo. 7. Recognition of aura may trigger the need to take medication before an attack occurs, thereby minimizing the severity of effects. 8. Sensation of vertigo decreases and motion decelerates if eyes are kept in a fixed position.
Nursing Diagnosis: Impaired adjustment related to disability requiring change in lifestyle due to unpredictability of vertigo Goal: Modifies lifestyle to decrease disability and exert maximum control and independence within limits posed by chronic vertigo 1. Encourage patient to identify personal strengths and roles that can still be fulfilled. 2. Provide information about vertigo and what to expect. 3. Include family and significant others in rehabilitative process. 4. Encourage patient to maintain sense of control by making decisions and assuming more responsibility for care.
1. Maximizes sense of regaining control and independence
• Exerts maximum control of environment
2. Reduces fear and anxiety
• •
3. Perceived beliefs of significant others are important for patient’s adherence to medical regimen. 4. Reinforces positive psychological and social outcomes
•
and independence within limits imposed by vertigo Is informed about condition Family and significant others are included in rehabilitation process Uses strengths and potentials to engage in the most independent and constructive lifestyle
Nursing Diagnosis: Risk for deficient fluid volume related to increased fluid output, altered intake, and medications Goal: Maintains a normal fluid-electrolyte balance 1. Assess, or have patient assess, intake and output (including emesis, liquid stools, urine, and diaphoresis). Monitor laboratory values. 2. Assess indicators of dehydration, including blood pressure (orthostasis), pulse, skin turgor, mucous membranes, and level of consciousness.
1. Accurate records provide basis for fluid replacement. 2. Prompt recognition of dehydration allows early intervention.
• Laboratory values within normal limits • Alert and oriented; vital signs within nor• •
mal limits, skin turgor normal; electrolytes normal Mucous membranes are moist Vomiting or diarrhea has stopped; usual oral intake resumed
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Plan of Nursing Care Care of the Patient With Vertigo (Continued) Nursing Interventions
Rationale
3. Encourage oral fluids as tolerated; discourage beverages containing caffeine (a vestibular stimulant). 4. Administer, or teach administration of, antiemetics and antidiarrheal medication as prescribed and needed. Instruct patient in side effects.
3. Oral replacement is begun as soon as possible to replace losses. Caffeine may increase diarrhea. 4. Antiemetics reduce nausea and vomiting, reducing fluid losses and improving oral intake. Antidiarrheal medication reduces intestinal motility and fluid losses.
Expected Patient Outcomes
Nursing Diagnosis: Anxiety related to threat of, or change in, health status and disability effects of vertigo Goal: Experiences less or no anxiety 1. Assess level of anxiety. Help patient identify coping skills used successfully in the past. 2. Provide information about vertigo and its treatment. 3. Encourage patient to discuss anxieties and explore concerns about vertigo attacks. 4. Teach patient stress management techniques or make appropriate referral. 5. Provide comfort measures and avoid stress-producing activities. 6. Instruct patient in aspects of treatment regimen.
1. Guides therapeutic interventions and participation in self-care. Past coping skills can relieve anxiety. 2. Increased knowledge helps to decrease anxiety. 3. Promotes awareness and understanding of relationship between anxiety level and behavior 4. Improved stress management can reduce the frequency and severity of some vertiginous attacks. 5. Stressful situations may exacerbate symptoms of the condition. 6. Patient knowledge helps to decrease anxiety.
• Fear and anxiety about attacks of vertigo reduced or eliminated
• Acquires knowledge and skills to deal with vertigo
• Feels less tension, apprehension, and uncertainty
• Uses stress management techniques when needed
• Avoids upsetting encounters • Repeats instructions given and verbalizes understanding of treatments
Nursing Diagnosis: Risk for trauma related to impaired balance Goal: Reduces the risk of trauma by adapting the home environment and by using rehabilitative devices as necessary 1. Assess for balance disturbance and/or vertigo by taking history and by examination for nystagmus, positive Romberg, and inability to perform tandem Romberg. 2. Assist with ambulation when indicated. 3. Assess for visual acuity and proprioceptive deficits. 4. Encourage increased activity level with or without use of assistive devices. 5. Help identify hazards in home environment.
1. Peripheral vestibular disorders cause these signs and symptoms. 2. Abnormal gait can predispose patient to unsteadiness and falls. 3. Balance depends on visual, vestibular, and proprioceptive systems. 4. Increased activity may help retrain balance system. 5. Adaptation of home environment can reduce risk of falls during rehabilitative process.
• Has adapted home environment or uses • • • •
rehabilitative devices to reduce risk of falling Ambulates with needed assistance Visual and proprioceptive risks identified Activity level increased Home environment free of hazards
Nursing Diagnosis: Ineffective coping related to personal vulnerability and disabling effects of vertigo Goal: Develops coping skills necessary to decrease vulnerability and unmet needs and demonstrates effective coping 1. Assess cognitive appraisal of illness and factors that may be contributing to inability to cope. 2. Provide factual information about treatment and future health status.
1. To improve patient’s self-image and to enhance coping process
• Copes effectively with vertigo • Has acquired knowledge and skills to cope
2. To clarify any misinformation or confusion
• Verbalizes less threatening appraisal of
with vertigo situation
(continued)
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Plan of Nursing Care Care of the Patient With Vertigo (Continued) Nursing Interventions
Rationale
Expected Patient Outcomes
3. Encourage and help patient to participate in decision making about adjustments in lifestyle. 4. Encourage patient to maintain diversional or recreational activities, exercise, and social events. 5. Help patient identify personal strengths and develop coping strategies based on previous positive experiences in dealing with stress, and situational supports. 6. Refer patient to support groups or counseling as indicated.
3. To help patient regain sense of power and control in self-care with activities of daily living 4. Social isolation and avoiding pleasant activities intensify isolation and reduce ability to cope with vertigo. 5. To enhance patient’s strengths that help maintain hope
• Is involved in outside activities • Identifies specific strategies for coping • Uses support groups or counseling as appropriate
6. May help patient feel less alone and isolated
Nursing Diagnosis: Deficient diversional activity related to environmental lack of such activity Goal: Engages in diversional activities 1. Assess level and type of diversional activity to plan appropriate activities. 2. Discuss usual pattern of diversional activities with patient. Suggest opportunities to continue meaningful diversional activities.
1. Boredom may be exhibited as well as depression; helps determine tolerances as well as preferences. 2. To provide information about perceived and actual stressors that influence activity level; to support patient’s sense of selfworth and productivity.
• Verbalizes decreased feelings of boredom and appears alert and animated
• Seeks realistic opportunities for involvement in diversional activities.
Nursing Diagnosis: Self-care deficit: feeding, bathing/hygiene, dressing/grooming, toileting, related to labyrinth dysfunction and episodes of vertigo Goal: Able to care for self 1. Administer, or teach administration of, antiemetics and other prescribed medications to relieve nausea and vomiting associated with vertigo. 2. Encourage patient to perform self-care when free of vertigo. 3. Review diet with patient and caregivers. Offer fluids as necessary.
1. Antiemetics and sedative-type medications depress stimuli in the cerebellum. 2. Spacing activities is important because episodes of vertigo vary in occurrence. 3. Sodium restriction helps improve an inner ear fluid imbalance in some patients, thereby decreasing vertigo. Fluids help prevent dehydration.
• Carries out necessary functions during • • •
symptom-free periods. Takes medications to relieve nausea or vomiting. Carries out daily activities Accepts dietary plan and reports its effectiveness. Drinks fluids in sufficient amounts
Nursing Diagnosis: Powerlessness related to illness regimen and being helpless in certain situations due to vertigo/balance disturbance Goal: Experiences increased sense of control over life and activities despite vertigo/balance disturbance 1. Assess patient’s needs, values, attitudes, and readiness to initiate activities. 2. Provide opportunities for patient to express feelings about self and illness. 3. Help patient identify previous coping behaviors that were successful.
1. Involving patient in planning activities and care enhances potential for mastery. 2. Expressing feelings increases understanding of individual coping styles and defense mechanisms. 3. Awareness increases understanding of stressors that trigger feeling of powerlessness. Awareness of past successes enhances self-confidence.
• Does not restrict activities unnecessarily due to vertigo
• Verbalizes positive feelings about own ability to achieve a sense of power and control
• Identifies previous successful coping behaviors
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workup can be performed to rule out an acoustic neuroma. MRI with a paramagnetic contrast agent (ie, gadolinium or Magnevist) is the imaging study of choice. If the patient is claustrophobic or cannot tolerate an MRI or if the scan is unavailable, a computed tomography (CT) scan with contrast dye is performed. However, MRI is more sensitive in delineating a small tumor than is CT.
Management Surgical removal of acoustic tumors is the treatment of choice because these tumors do not respond well to irradiation or chemotherapy. Because treatment of acoustic tumors crosses several specialties, the multidisciplinary treatment approach involves a neurotologist and a neurosurgeon. The objective of the surgery is to remove the tumor while preserving facial nerve function. Most acoustic tumors have damaged the cochlear portion of cranial nerve VIII, and no serviceable hearing exists before surgery. In these patients, the surgery is performed using a translabyrinthine approach, and the hearing mechanism is destroyed. If hearing is still good before surgery, a suboccipital or middle cranial fossa approach to removing the tumor may be used, and intraoperative monitoring of cranial nerve VIII is performed to save the hearing. Complications of surgery for acoustic neuroma include facial nerve paralysis, cerebrospinal fluid leak, meningitis, and cerebral edema. Death from acoustic neuroma surgery is rare.
A
B
FIGURE 59-9
The Dix-Hallpike maneuver is the test used to assess for benign paroxysmal positional vertigo (BPPV). (A) The patient sits on the examination table with the head turned to the left at a 45-degree angle. (B) The patient is lowered quickly to a supine position with the head turned to one side and slightly lower than the head of the examination table. The patient’s eyes should remain open so that the examiner can observe for nystagmus. If the patient has BPPV, vertigo occurs within 5 to 10 seconds and lasts about 30 seconds. Rotary nystagmus and dizziness also occur. The procedure is repeated on the opposite side. Vertigo occurs when the affected ear faces toward the ground.
middle age. Most acoustic neuromas are unilateral, except in von Recklinghausen’s disease (ie, neurofibromatosis type 2), in which bilateral tumors occur.
Assessment and Diagnostic Findings The most common findings of assessment of patients with an acoustic neuroma are unilateral tinnitus and hearing loss with or without vertigo or balance disturbance. It is important to identify asymmetry in audiovestibular test results so that further
Aural Rehabilitation If hearing loss is permanent or cannot be treated by medical or surgical means or if the patient elects not to undergo surgery, aural rehabilitation may be beneficial. The purpose of aural rehabilitation is to maximize the hearing-impaired person’s communication skills. Aural rehabilitation includes auditory training, speech reading, speech training, and the use of hearing aids and hearing guide dogs. Auditory training emphasizes listening skills, so the hearingimpaired person concentrates on the speaker. Speech reading (formerly known as lip reading) can help fill the gaps left by missed or misheard words. Speech training attempts to conserve, develop, and prevent deterioration of current skills. It is important to identify the type of hearing impairment a person has so that rehabilitative efforts can be directed at his or her particular need. Surgical correction may be all that is necessary to treat and improve a conductive hearing loss (Fig. 59-10). With advances in hearing aid technology, amplification for patients with sensorineural hearing loss is more helpful than ever before.
HEARING AIDS
Chart 59-6
• PHARMACOLOGY
Selected Ototoxic Substances Diuretics: ethacrynic acid, furosemide, acetazolamide Chemotherapeutic agents: cisplatin, nitrogen mustard Antimalarial agents: quinine, chloroquine Anti-inflammatory agents: salicylates (aspirin), indomethacin Chemicals: alcohol, arsenic Aminoglycoside antibiotics: amikacin, gentamicin, kanamycin, netilmicin, neomycin, streptomycin, tobramycin Other antibiotics: erythromycin, minocycline, polymyxin B, vancomycin Metals: gold, mercury, lead
A hearing aid is a device through which speech and environmental sounds are received by a microphone, converted to electrical signals, amplified, and reconverted to acoustic signals. Many aids available for sensorineural hearing loss depress the low frequencies, or tones, and enhance hearing for the high frequencies. A general guideline for assessing the patient’s need for a hearing aid is a hearing loss exceeding 30 dB in the range of 500 to 2000 Hz in the better-hearing ear. The evolution in technology has led to the availability of many smaller and more effective hearing aids. It is estimated that 98% of all hearing aids sold today are behind-the-ear, in-the-ear, or in-the-canal types (Table 59-4). A hearing aid should be fitted according to the patient’s needs (eg, type of hearing loss, manual dexterity), rather than the brand
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Assessment and Management of Patients With Hearing and Balance Disorders
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FIGURE 59-10
Management flow chart for conductive hearing loss. The flow chart indicates how the diagnosis determines the management of the patient and predicts the outcome. From Jafek, B. W. & Balkany, T. J. Conductive hearing loss. In B. Eiseman (Ed.). Prognosis of surgical disease. Philadelphia: W. B. Saunders.
name, by a certified audiologist licensed to dispense hearing aids. Many states have a consumer protection law that allows the hearing aid to be returned after a trial use if the patient is not completely satisfied. A hearing aid makes sounds louder, but it does not improve a patient’s ability to discriminate words or understand speech. People
Table 59-4
who have low discrimination scores (ie, 20%) on audiograms may derive little benefit from a hearing aid. Hearing aids amplify all sounds, including background noise, which may be disturbing to the wearer. Chart 59-7 identifies additional problems associated with hearing aid use. There are, however, computerized hearing aids available that compensate for background noise or allow
• Hearing Aids
SITE (AND RANGE OF HEARING LOSS)
ADVANTAGES
DISADVANTAGES
Body (mild–profound)
Separation of receiver and microphone prevents acoustic feedback, allowing high amplification. Generally used in a school setting. Larger size permits use of larger components that enable the aid to provide more power and features; most versatile due to size; no long wires One-piece custom fit to contour of ear; no tubes or cords; miniature microphone is located in the ear, which is a more natural placement; more cosmetically appealing due to easy concealment Same as in-the-ear aids; less visible, so more cosmetically pleasing
Bulky; requires long wire, which may be cosmetically displeasing; some loss of highfrequency response Large size
Behind the ear (mild–profound) In the ear (mild–moderately severe)
In the canal (mild–moderately severe)
Smaller size limits output; patients who have arthritis or cannot perform tasks requiring good manual dexterity may have difficulty with the small size of aid and/or battery; can require more repair than the behind-the-ear aid Even smaller than in-the-ear aids; requires good manual dexterity
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Chart 59-7
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Hearing Aid Problems
Whistling Noise Loose ear mold Improperly made Improperly worn Worn out Improper Aid Selection Too much power required in aid, with inadequate separation between microphone and receiver Open mold used inappropriately Inadequate Amplification Dead batteries Wax in ear Wax or other material in mold Wires or tubing disconnected from aid Aid turned off or volume too low Improper mold Improper aid for degree of loss Pain from Mold Improperly fitted mold Ear skin or cartilage infection Middle ear infection Ear tumor Unrelated conditions of the temporomandibular joint, throat, or larynx
amplification at certain programmed frequencies rather than at all frequencies. Occasionally, depending on the type of hearing loss, binaural aids (ie, one for each ear) may be indicated. Chart 59-8 provides tips for hearing aid care. To protect the health and safety of people with hearing impairments, the U.S. Food and Drug Administration (FDA) has established certain regulations. A medical evaluation of the impairment by a licensed physician must be obtained within 6 months before the purchase of a hearing aid. The written statement from a physician may be waived, however, if the patient (a fully informed adult 18 years of age or older) signs a document to this effect.
Chart 59-8
• PATIENT EDUCATION Tips for Hearing Aid Care Cleaning The ear mold is the only part of the hearing aid that may be washed frequently (even daily if necessary) with soap and water. The ear mold must be dry before it is snapped into the receiver. The cannula is cleaned with a small pipe cleaner–like device. Malfunctioning Inadequate amplification, a whistling noise, or pain from the mold can occur when a hearing aid is not functioning properly. Check for malfunctions: Is the switch on? Are the batteries charged and positioned correctly? If the hearing aid still does not work properly, the hearing aid dealer should be notified. If the unit requires extended time for repair, the dealer may lend the patient a hearing aid until the repair can be accomplished. Recognizing Complications When occluded by a hearing aid, the external auditory canal can become moist. Common medical problems among hearing aid wearers include external otitis and pressure ulcers in the external auditory canal or meatus.
Children must be evaluated by a physician. Health care professionals who dispense hearing aids are required to refer prospective users to a physician if any of the following otologic conditions are evident:
• Visible congenital or traumatic deformity of the ear • Active drainage from the ear within the previous 90 days • Sudden or rapidly progressive hearing loss within the previous 90 days
• Complaints of dizziness or tinnitus • Unilateral hearing loss that occurred suddenly or within the previous 90 days
• Audiometric air–bone gap of 15 dB or more at 500, 1000, and 2000 Hz
• Significant accumulation of cerumen or a foreign body in the external auditory canal
• Pain or discomfort in the ear A user instruction brochure is to accompany every hearing aid device. In this brochure, the following information is presented:
• Specification that good health practice requires a medical evaluation before purchasing a hearing aid
• Notification that any of the eight otologic conditions pre• • • •
viously listed should be investigated by a physician before purchase of a hearing aid Instructions for proper use, maintenance, and care of the hearing aid, as well as instructions for replacing or recharging the batteries Repair service information Description of avoidable conditions that could damage the hearing aid List of any known side effects that may warrant physician consultation (eg, skin irritation, accelerated cerumen accumulation)
IMPLANTED HEARING DEVICES Three types of implanted hearing devices are commercially available or in the investigational stage: the cochlear implant, the bone conduction device, and the semi-implantable hearing device. Cochlear implants are for patients with little or no hearing. Bone conduction devices, which transmit sound through the skull to the inner ear, are used in patients with a conductive hearing loss if a hearing aid is contraindicated (eg, those with chronic infection). The device is implanted postauricularly under the skin into the skull, and an external device—worn above the ear, not in the canal—transmits the sound through the skin. Semi-implantable hearing aids, although not yet approved by the FDA except in testing sites, still require the use of an external device. However, research to develop a fully implantable hearing aid continues.
Cochlear Implant A cochlear implant is an auditory prosthesis used for people with profound sensorineural hearing loss bilaterally who do not benefit from conventional hearing aids. The hearing loss may be congenital or acquired. An implant does not restore normal hearing; rather, it helps the person detect medium to loud environmental sounds and conversation. The implant is designed to provide stimulation directly to the auditory nerve, bypassing the hair cells of the inner ear, which are not functioning. The microphone and signal processor are worn outside the body and transmit electrical stimuli inside the body to the implanted electrodes. The electrical signals stimulate the auditory nerve fibers and then the brain, where they are interpreted.
Chapter 59
Assessment and Management of Patients With Hearing and Balance Disorders External coil
Internal coil Malleus
Incus Stapes
FIGURE 59-11 The cochlear implant. The internal coil has a stranded electrode lead. The electrode is inserted through the round window into the scala tympani of the cochlea. The external coil (the transmitter) is held in alignment with the internal coil (the receiver) by a magnet. The microphone receives the sound. The stimulator wire receives the signal after it has been filtered, adjusted, and modified so that the sound is at a comfortable level for the patient. Sound is passed by the external transmitter to the inner coil receiver by magnetic conduction and is then carried by the electrode to the cochlea.
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Acoustic nerve
Cochlea Microphone Tympanic membrane
Earmold External auditory canal
Ground electrode
Active electrode
Eustachian tube
Stimulator wires
Candidates for a cochlear implant, who are usually at least 1 year old, are selected after careful screening by otologic history, physical examination, audiologic testing, x-rays, and psychological testing. Several criteria apply for choosing adults who may benefit from a cochlear implant: • Profound sensorineural hearing loss in both ears • Inability to hear and recognize speech well with hearing aids • No medical contraindication to a cochlear implant or general anesthesia • Indications that being able to hear would enhance the patient’s life The surgery involves implanting a small receiver in the temporal bone through a postauricular incision and placing electrodes into the inner ear (Fig. 59-11). The microphone and transmitter are worn on an external unit. The patient undergoes extensive cochlear rehabilitation with the multidisciplinary team, which includes an audiologist and speech pathologist. Several months may be needed to learn to interpret the sounds heard. Children and adults who lost their hearing before they learned to speak take much longer to acquire speech. There are wide variations of success with cochlear implants, and there is also controversy about their use, especially among the Deaf community. Patients who have had a cochlear implant are cautioned that an MRI will cause the implant to become inactivated; MRI is to be used only when unavoidable.
HEARING GUIDE DOGS Specially trained dogs are available to assist the person with a hearing loss. People who live alone are eligible to apply for a dog trained by International Hearing Dog, Inc. At home, the dog reacts to the sound of a telephone, a doorbell, an alarm clock, a baby’s cry, a knock at the door, a smoke alarm, or an intruder. The dog does not bark but alerts its master by physical contact; the dog then runs to the source of the noise. In public, the dog positions itself between the hearing-impaired person and any potential hazard that the person cannot hear, such as an oncoming vehicle or a loud, hostile person. In many states, a hearing-impaired person with a certified hearing guide dog is legally permitted access to public transportation, public eating places, and stores, including food markets.
?
Critical Thinking Exercises
1.
An 82-year-old patient in an extended care facility appears withdrawn and distrustful of others. She does not participate in conversations with other residents. You suspect that she has a hearing loss. Describe the strategies you would use to assess this patient’s hearing. What intervention strategies would you implement if your assessment confirms that the woman has a hearing loss? What intervention strategies would you implement if your assessment indicates that she does not have a hearing loss?
2.
An antiemetic and a tranquilizer have been prescribed for a patient with Ménière’s disease. You realize that safety precautions are indicated. Devise a teaching plan for this patient, and explain the reasons behind each part of the plan.
3.
A teenage boy has decided to play the drums in a local band. The music consists of loud, hard rock music. The group practices for 2 to 3 hours each day, approximately 4 nights per week. Describe the teaching plan you would devise for this teenage boy, including rationale.
4.
A patient presents with severe vertigo. She lives alone and is afraid of injuring herself because of her dizziness, which is unpredictable. Devise a teaching plan for this patient, including methods to prevent injury. Include interventions and outcomes that will address her fears and anxiety.
5.
A patient with severe hearing loss is admitted for abdominal surgery to treat a bowel obstruction. It is anticipated that a colostomy will be created. Explain modifications in preoperative, intraoperative, and postoperative nursing care needed because of her impaired hearing.
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REFERENCES AND SELECTED READINGS Books Alper, C., Eibling, D., & Myers, E. (2001). Decision making in ear, nose and throat disorders. Philadelphia: W. B. Saunders. Blitzer, A. (Ed.). (1998). Office-based surgery in otolaryngology. New York: Thieme. Canalis, A., & Lambert, P. (2000). The ear: Comprehensive otology. Philadelphia: Lippincott Williams & Wilkins. Charles, E. (1999). Introduction to sound: Acoustics for the hearing and speech sciences. San Diego: Singular Publishing Group. Goroll, A., Mulley, A. G., Jr., & May, L. A. (Eds.). (2000). Primary care medicine: Office evaluation and management of the adult patient. Philadelphia: Lippincott Williams & Wilkins. Harris, L. L., & Huntoon, M. B. (1998). Core curriculum for otorhinolaryngology and head/neck nursing. New Smyrna Beach, FL: Society of Otorhinolaryngology and Head–Neck Nurses. National Institute on Deafness and Other Communication Disorders (NIDCD). (1998). NIDCD national strategic research plan. Narberth, PA: National Institutes of Health. Noble, J., Greene, H. L., & Levinson, W. (2001). Textbook of primary care medicine. St. Louis: C. V. Mosby. Patton, K., & Thibodeau, G. (2000). Mosby’s Handbook of anatomy & physiology. St. Louis: C. V. Mosby. Society of Otorhinolaryngology–Head and Neck Nurses, Inc. (1996). Nursing practice guidelines for care of the otorhinolaryngology—head and neck patient. New Smyrna Beach, FL: Society of Otorhinolaryngology and Head–Neck Nurses. Woodson, G. (2001). Ear, nose and throat disorders in primary care. Philadelphia: Harcourt Health Sciences. U.S. Public Health Service. (2000). Healthy People 2010. Washington, DC: Author.
Journals Cavenish, R. (1998). Adult hearing loss. American Journal of Nursing, 98(8), 50–51. Cooley, D., Grossan, M., & Hoffman, D. (2002). The ins and outs of common ear problems. In Patient care for the nurse practitioner: 6. Montvale, NJ: Medical Economics Company. Cruickshanks, K. J., Wiley, T. L., Tweed, T. S., Klein, B. E., Klein, R., Mares-Perlman, J. A., & Nondahl, D. M. (1998). Prevalence of hearing loss in order adults in Beaver Dam Wisconsin: The epidemiology of hearing loss study. American Journal of Epidemiology, 148(9), 879–886. Epley, J. M. (1992). The canalith repositioning procedure: For treatment of benign paroxysmal positional vertigo. Otolaryngology— Head and Neck Surgery, 107(3), 399–404. Felis, M. (2000). Acute otitis externa. Lippincott’s Primary Care Practice, 5, 529–533. Franks, J. R. (1996). Analysis of audiograms for a large cohort of noiseexposed miners. Cincinnati, OH: HHS Centers for Disease Control & Prevention, NIOSH, Division of Biomedical and Behavioral Science. Hain, T. (2002). Benign paroxysmal positional vertigo. Online publication available at http://www.tchain.com/otoneurology/disorders/ bppv/bppv.html. Hannley, M., Denneny, J., & Holzer, S. (2000). Use of ototopical antibiotics in three common ear diseases. Otolaryngology—Head and Neck Surgery, 122(6), 934–940.
Kaplan, S. L., Mason, E. O., Wald, E. R., Kim, K. S., Givner, L. B., Bradley, J. S., et al. (2000). Pneumococcal mastoiditis in children. Pediatrics, 106(5), 695–699. Knox, G., & McPherson, A. (1997). Ménière’s disease: Differential diagnosis and treatment. American Family Physician, 55(4), 1185–1198. Larson, V. D., Williams, D. W., Henderson, W. G., Luethke, L. E., Beck, L. B., Noffsinger, D., et al. (2000). Efficacy of 3 commonly used hearing aid circuits: A crossover trial. Journal of the American Medical Association, 284(14), 1805–1813. Nobel, W., Ter-Horst, K., & Byrne, D. (1995). Disabilities and handicaps associated with impaired auditory localization. Journal of the American Academy of Audiology, 6(2), 129–140. Rabinowitz, P. (2000). Noise-induced hearing loss. American Family Physician, 6(5), 2749–2756, 2759–2760. Ruckenstein, M. (2000). Vertigo and dysequilibrium with associated hearing loss. Otolaryngologic Clinics of North America, 33(3), 535–562. Weber, P. C., & Klein, A. J. (1999). Hearing loss. Medical Clinics of North America, 83(3), 124.
RESOURCES AND WEBSITES Acoustic Neuroma Association, P.O. Box 12402, Atlanta, GA 30355; 770-205-8211; http://ANAusa.org. Alexander Graham Bell Association for the Deaf, Inc., 3417 Volta Place, NW, Washington, DC 20007-2778; 202-337-5220; http:// www.agbell.org/index.html. American Academy of Audiology, 8201 Greensboro Dr., Suite 300, McLean, VA 22102; 703-790-8466; http://www.audiology.com. American Academy of Facial Plastic and Reconstructive Surgery, 1101 Vermont Ave., NW, Suite 220, Washington, DC 20005-3522; 703-299-9291; http://www.aafprs.org. American Academy of Otolaryngology–Head and Neck Surgery, One Prince Street, Alexandria, VA 22314-3357; 703-836-4444; http:// www.entnet.org. American Board of Facial Plastic & Reconstructive Surgery, One Prince Street, Suite 310, Alexandria, VA 22314; 703-549-3223; http:// www.abfprs.org. American Speech-Language-Hearing Association, 10801 Rockville Pike, Rockville, MD 20852; 1-800-638-8255; http://www.asha.org. American Tinnitus Association, P.O. Box 5, Portland, OR 972070005; http://www.ata.org; http://www.surgeon.org/contacts/listings/ aafprs.htm. International Hearing Dog, Inc., 5901 E. 89th Ave., Henderson, CO 80640; 303-287-3277; http://members.aol.com/ihdi/IHDI.html. National Institute on Deafness and Other Communication Disorders, National Institutes of Health, Building 31, Room 3c35 9000, Rockville Pike, Bethesda, MD 20892; http://www.nidcd.nih.gov. Self-Help for Hard of Hearing People, Inc., 7910 Woodmont Ave., Suite 1200, Bethesda, MD 20814; 301-657-2248; http://www. shhh.org. Society of Otorhinolaryngology and Head–Neck Nurses, Inc., 116 Canal Street, Suite A, New Smyrna Beach, FL 32168; 904-428-1695; http://www.sohnnurse.com. Vestibular Disorders Association, P.O. Box 4467, Portland, OR 972084467; 503-229-7705; http://home.teleport.com/~veda.
Chapter
60 ●
Assessment of Neurologic Function
LEARNING OBJECTIVES
●
On completion of this chapter, the learner will be able to: 1. Describe the structures and functions of the central and peripheral 2. 3. 4. 5. 6.
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nervous systems. Differentiate between pathologic changes that affect motor control and those that affect sensory pathways. Compare the functioning of the sympathetic and parasympathetic nervous systems. Describe the significance of physical assessment to the diagnosis of neurologic dysfunction. Describe changes in neurologic function associated with aging and their impact on neurologic assessment findings. Describe diagnostic tests used for assessment of suspected neurologic disorders and the related nursing implications.
Chapter 60
N
urses in many types of practice settings encounter patients with altered neurologic function. Disorders of the nervous system can occur at any time during the life span and can vary from mild, self-limiting symptoms to devastating, life-threatening disorders. The nurse must be skilled in the assessment of the neurologic system whether the assessment is generalized or focused on specific areas of function. Assessment in either case requires knowledge of the anatomy and physiology of the nervous system and an understanding of the array of tests and procedures used to diagnose neurologic disorders. Knowledge about the nursing implications and interventions related to assessment and diagnostic testing is also essential.
Anatomic and Physiologic Overview The nervous system consists of two divisions: the central nervous system (CNS), including the brain and spinal cord, and the peripheral nervous system, made up of the cranial and spinal nerves. The peripheral nervous system can be further divided into the somatic, or voluntary, nervous system, and the autonomic, or involuntary, nervous system. The function of the nervous system is to control all motor, sensory, autonomic, cognitive, and behavioral activities. The nervous system has approximately 10 million sensory neurons that send information about the internal and external environment to the brain and 500,000 motor neurons that control the muscles and glands. The brain itself contains more than 20 billion nerve cells that link the motor and sensory pathways, monitor the body’s processes, respond to the internal and external environment, maintain homeostasis, and direct all psychological, biologic, and physical activity through complex chemical and electrical messages (Bradley, Daroff, Fenichel & Marsden, 2000).
ANATOMY OF THE NERVOUS SYSTEM Cells of the Nervous System The basic functional unit of the brain is the neuron (Fig. 60-1). It is composed of a cell body, a dendrite, and an axon. The dendrite is a branch-type structure with synapses for receiving electrochemical messages. The axon is a long projection that carries
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impulses away from the cell body. Nerve cell bodies occurring in clusters are called ganglia or nuclei. A cluster of cell bodies with the same function is called a center (eg, the respiratory center). Neuroglial cells, another type of nerve cell, support, protect, and nourish neurons.
Neurotransmitters Neurotransmitters communicate messages from one neuron to another or from a neuron to a specific target tissue. Neurotransmitters are manufactured and stored in synaptic vesicles. They enable conduction of impulses across the synaptic cleft. The neurotransmitter has an affinity for specific receptors in the postsynaptic bulb. When released, the neurotransmitter crosses the synaptic cleft and binds to receptors in the postsynaptic cell membrane. The action of a neurotransmitter is to potentiate, terminate, or modulate a specific action and can either excite or inhibit the target cell’s activity. There are usually multiple neurotransmitters at work in the neural synapse. There are various types of neurotransmitters (Bradley et al., 2000; Hickey, 2003); major neurotransmitters are described in Table 60-1. Many neurologic disorders are due, at least in part, to an imbalance in neurotransmitters—that is, a lack of gammaaminobutyric acid (GABA) and acetylcholine in Huntington’s disease (Bradley et al., 2000), low serotonin levels in some forms of epilepsy (Blows, 2000), and a decrease in dopamine in Parkinson’s disease. In fact, probably all brain functions are modulated through neurotransmitter receptor site activity, including memory and other cognitive processes. There are two types of receptors: direct and indirect. Direct receptors are also known as inotropic because they are linked to ion channels and allow passage of ions when opened. They can be excitatory or inhibitory and are rapid-acting (measured in milliseconds). Indirect receptors affect metabolic processes in the cell, which can take from seconds to hours to occur. Receptor sites are an expanding area of research because they are often the target for the action and development of new medications. These medications either block or stimulate neurotransmitters at receptor sites and thus provide relief from symptoms (Blows, 2000). Receptor sites are also sites for the action of addictive drugs.
Glossary agnosia: loss of ability to recognize objects through a particular sensory system; may be visual, auditory, or tactile ataxia: inability to coordinate muscle movements, resulting in difficulty in walking, talking, and performing self-care activities autonomic nervous system: division of the nervous system that regulates the involuntary body functions axon: portion of the neuron that conducts impulses away from the cell body Babinski reflex (sign): a reflex action of the toes, indicative of abnormalities in the motor control pathways leading from the cerebral cortex clonus: abnormal movement marked by alternating contraction and relaxation of a muscle occurring in rapid succession
delirium: transient loss of intellectual function, usually due to systemic problems dendrite: portion of the neuron that conducts impulses toward the cell body dysphagia: difficulty swallowing flaccid: displaying lack of muscle tone; limp, floppy myelography (myelogram): x-ray study of the spinal cord after injection of a contrast agent into the subarachnoid space parasympathetic nervous system: division of the autonomic nervous system active primarily during nonstressful conditions, controlling mostly visceral functions photophobia: inability to tolerate light position (postural) sense: awareness of position of parts of the body without looking at them; also referred to as proprioception
rigidity: increase in muscle tone at rest characterized by increased resistance to passive stretch reflex: an automatic response to stimuli Romberg test: test for cerebellar dysfunction requiring the patient to stand with feet together, eyes closed and arms extended; inability to maintain the position, with either significant stagger or sway, is a positive test spasticity: sustained increase in tension of a muscle when it is passively lengthened or stretched sympathetic nervous system: division of the autonomic nervous system with predominantly excitatory responses, the “fight-or-flight” system tone: tension present in a muscle at rest
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Nucleus
Myelin sheath Axon
Node Neurolemma Synaptic terminals
Dendrites
FIGURE 60-1 Another important area of ongoing research is diagnostic testing that can detect abnormal levels of neurotransmitters in the brain. Positron emission tomography (PET), for example, can detect dopamine, serotonin, and acetylcholine (Gjedde et al., 2001). Single photon emission computed tomography (SPECT) is similar to PET. Both PET and SPECT are discussed in more detail later in this chapter.
The Central Nervous System ANATOMY OF THE BRAIN The brain is divided into three major areas: the cerebrum, the brain stem, and the cerebellum. The cerebrum is composed of two hemispheres, the thalamus, the hypothalamus, and the basal ganglia. Additionally, connections for the olfactory (cranial nerve I) and optic (cranial nerve III) nerves are found in the cerebrum. The brain stem includes the midbrain, pons, medulla, and connections for cranial nerves II and IV through XII. The cerebellum is located under the cerebrum and behind the brain stem (Fig. 60-2). The brain accounts for approximately 2% of the total body weight; it weighs approximately 1,400 g in an average young adult (Hickey, 2003). In the elderly, the average brain weighs approximately 1,200 g. Cerebrum. The cerebrum consists of two hemispheres that are incompletely separated by the great longitudinal fissure. This sulcus separates the cerebrum into the right and left hemispheres. The two hemispheres are joined at the lower portion of the fis-
Table 60-1
Neuron.
sure by the corpus callosum. The outside surface of the hemispheres has a wrinkled appearance that is the result of many folded layers or convolutions called gyri, which increase the surface area of the brain, accounting for the high level of activity carried out by such a small-appearing organ. The external or outer portion of the cerebrum (the cerebral cortex) is made up of gray matter approximately 2 to 5 mm in depth; it contains billions of neurons/cell bodies, giving it a gray appearance. White matter makes up the innermost layer and is composed of nerve fibers and neuroglia (support tissue) that form tracts or pathways connecting various parts of the brain with one another (transverse and association pathways) and the cortex to lower portions of the brain and spinal cord (projection fibers). The cerebral hemispheres are divided into pairs of frontal, parietal, temporal, and occipital lobes. The four lobes are as follows (see Fig. 60-2):
• Frontal—the largest lobe. The major functions of this lobe
•
are concentration, abstract thought, information storage or memory, and motor function. It also contains Broca’s area, critical for motor control of speech. The frontal lobe is also responsible in large part for an individual’s affect, judgment, personality, and inhibitions. Parietal—a predominantly sensory lobe. The primary sensory cortex, which analyzes sensory information and relays the interpretation of this information to the thalamus and other cortical areas, is located in the parietal lobe. It is also essential to an individual’s awareness of the body in space, as well as orientation in space and spatial relations.
• Major Neurotransmitters
NEUROTRANSMITTER
SOURCE
ACTION
Acetylcholine (major transmitter of the parasympathetic nervous system)
Many areas of the brain; autonomic nervous system
Serotonin
Brain stem, hypothalamus, dorsal horn of the spinal cord Substantia nigra and basal ganglia
Usually excitatory; parasympathetic effects sometimes restrain (stimulation of heart by vagal nerve) Restraining, helps control mood and sleep, inhibits pain pathways Usually restrains, affects behavior (attention, emotions) and fine movement Usually excitatory; affects mood and overall activity
Dopamine Norepinephrine (major transmitter of the sympathetic nervous system) Gamma-aminobutyric acid (GABA) Enkephalin, endorphin
Brain stem, hypothalamus, postganglionic neurons of the sympathetic nervous system Spinal cord, cerebellum, basal ganglia, some cortical areas Nerve terminals in the spine, brain stem, thalamus and hypothalamus, pituitary gland
Excitatory amino acid Excitatory; pleasurable sensation, inhibits pain transmission
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Central fissure (Rolando) Parietal lobe Gyri Frontal lobe
Lateral fissure (Sylvius)
Occipital lobe
Transverse fissure
Temporal lobe Midbrain Pons
Cerebellum
Medulla oblongata
FIGURE 60-2
View of the external surface of the brain showing lobes, cerebellum, and brain stem.
Spinal cord
• Temporal—contains the auditory receptive areas. Contains
•
a vital area called the interpretive area that provides integration of somatization, visual, and auditory areas and plays the most dominant role of any area of the cortex in cerebration. Occipital—the posterior lobe of the cerebral hemisphere is responsible for visual interpretation.
The corpus callosum (Fig. 60-3) is a thick collection of nerve fibers that connects the two hemispheres of the brain and is responsible for the transmission of information from one side of the brain to the other. Information transferred includes sensation, memory, and learned discrimination. Right-handed people and some left-handed people have cerebral dominance on the left side of the brain for verbal, linguistic, arithmetical, calculating, and Corpus callosum Thalamus
Hypothalamus
Pituitary
FIGURE 60-3
Medial view of the brain.
analytic functions. The nondominant hemisphere is responsible for geometric, spatial, visual, pattern, and musical functions. The basal ganglia are masses of nuclei located deep in the cerebral hemispheres that are responsible for control of fine motor movements, including those of the hands and lower extremities. The thalamus (see Fig. 60-3) lies on either side of the third ventricle and acts primarily as a relay station for all sensation except smell. All memory, sensation, and pain impulses also pass through this section of the brain. The hypothalamus is located anterior and inferior to the thalamus. The hypothalamus lies immediately beneath and lateral to the lower portion of the wall of the third ventricle. It includes the optic chiasm (the point at which the two optic tracts cross) and the mamillary bodies (involved in olfactory reflexes and emotional response to odors). The infundibulum of the hypothalamus connects it to the posterior pituitary gland. The hypothalamus plays an important role in the endocrine system because it regulates the pituitary secretion of hormones that influence metabolism, reproduction, stress response, and urine production. It works with the pituitary to maintain fluid balance and maintains temperature regulation by promoting vasoconstriction or vasodilatation. The hypothalamus is the site of the hunger center and is involved in appetite control. It contains centers that regulate the sleep–wake cycle, blood pressure, aggressive and sexual behavior, and emotional responses (ie, blushing, rage, depression, panic, and fear). The hypothalamus also controls and regulates the autonomic nervous system. The pituitary gland is located in the sella turcica at the base of the brain and is connected to the hypothalamus. The pituitary is a common site for brain tumors in adults; frequently they are detected by physical signs and symptoms that can be traced to the pituitary, such as hormonal imbalance or visual disturbances
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secondary to pressure on the optic chiasm (further information on brain tumors is found later in this unit in Chap. 65). Nerve fibers from all portions of the cortex converge in each hemisphere and exit in the form of a tight bundle of nerve fibers known as the internal capsule. Having entered the pons and the medulla, each bundle crosses to the corresponding bundle from the opposite side. Some of these axons make connections with axons from the cerebellum, basal ganglia, thalamus, and hypothalamus; some connect with the cranial nerve cells. Other fibers from the cortex and the subcortical centers are channeled through the pons and the medulla into the spinal cord. Although the various cells in the cerebral cortex are quite similar in appearance, their functions vary widely, depending on location. The topography of the cortex in relation to certain of its functions is shown in Figure 60-4. The posterior portion of each hemisphere (ie, the occipital lobe) is devoted to all aspects of visual perception. The lateral region, or temporal lobe, incorporates the auditory center. The midcentral zone, or parietal zone, posterior to the fissure of Rolando, is concerned with sensation; the anterior portion is concerned with voluntary muscle movements. The large area behind the forehead (ie, the frontal lobes) contains the association pathways that determine emotional attitudes and responses and contribute to the formation of thought processes. Damage to the frontal lobes as a result of trauma or disease is by no means incapacitating from the standpoint of muscular control or coordination, but it affects a person’s personality, as reflected by basic attitudes, sense of humor and propriety, selfrestraint, and motivations. (Neurologic trauma and disease states that may result in frontal damage are discussed in later chapters in this unit.)
pons and the cerebellum with the cerebral hemispheres; it contains sensory and motor pathways and serves as the center for auditory and visual reflexes. Cranial nerves III and IV originate in the midbrain. The pons is situated in front of the cerebellum between the midbrain and the medulla and is a bridge between the two halves of the cerebellum, and between the medulla and the cerebrum. Cranial nerves V through VIII connect to the brain in the pons. The pons contains motor and sensory pathways. Portions of the pons also control the heart, respiration, and blood pressure. The medulla oblongata contains motor fibers from the brain to the spinal cord and sensory fibers from the spinal cord to the brain. Most of these fibers cross, or decussate, at this level. Cranial nerves IX through XII connect to the brain in the medulla.
Brain Stem. The brain stem consists of the midbrain, pons, and medulla oblongata (see Fig. 60-2). The midbrain connects the
• Dura mater—the outermost layer; covers the brain and the
Motor cortex
Cerebellum. The cerebellum is separated from the cerebral hemispheres by a fold of dura mater, the tentorium cerebelli. The cerebellum has both excitatory and inhibitory actions and is largely responsible for coordination of movement. It also controls fine movement, balance, position sense (awareness of where each part of the body is), and integration of sensory input. STRUCTURES PROTECTING THE BRAIN The brain is contained in the rigid skull, which protects it from injury. The major bones of the skull are the frontal, temporal, parietal, and occipital bones. These bones join at the suture lines (Fig. 60-5). The meninges (fibrous connective tissues that cover the brain and spinal cord) provide protection, support, and nourishment to the brain and spinal cord. The layers of the meninges are the dura, arachnoid, and pia mater (Fig. 60-6). spinal cord. It is tough, thick, inelastic, fibrous, and gray.
Sensory area (pain, touch, etc.)
Written speech Visual interpretation area
Motor speech
Auditory receiving area
Visual receiving area
Auditory interpretation area
FIGURE 60-4
Topography of the cortex as it relates to function.
Chapter 60 Sagittal suture Parietal bone Coronal suture Lambdoidal suture
Frontal bone
•
Sphenoid bone Nasal bone Zygomatic bone
Occipital bone Squamosal suture Temporal bone Mastoid process
FIGURE 60-5
Maxilla
Mandible
•
Bones and sutures of the skull.
There are four extensions of the dura: the falx cerebri, which separates the two hemispheres in a longitudinal plane; the tentorium, which is an infolding of the dura that forms a tough membranous shelf; the falx cerebelli, which is between the two lateral lobes of the cerebellum; and the diaphragm sellae, which provides a “roof ” for the sella turcica. The tentorium supports the hemispheres and separates them from the lower part of the brain. When excess pressure occurs in the cranial cavity, brain tissue may be compressed against the tentorium or displaced downward, a
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process called herniation. Between the dura mater and the skull in the cranium, and between the periosteum and the dura in the vertebral column, is the epidural space, a potential space. Arachnoid—the middle membrane; an extremely thin, delicate membrane that closely resembles a spider web (hence the name arachnoid). It appears white because it has no blood supply. The arachnoid layer contains the choroid plexus, which is responsible for the production of cerebrospinal fluid (CSF). This membrane also has unique fingerlike projections, arachnoid villi, that absorb CSF. In the normal adult, approximately 500 mL of CSF is produced each day; all but 125 to 150 mL is absorbed by the villi (Hickey, 2003). When blood enters the system (from trauma or hemorrhagic stroke), the villi become obstructed and hydrocephalus (increased size of ventricles) may result. The subdural space is between the dura and the arachnoid layer, and the subarachnoid space is located between the arachnoid and pia layers and contains the CSF. Pia mater—the innermost membrane; a thin, transparent layer that hugs the brain closely and extends into every fold of the brain’s surface.
CEREBROSPINAL FLUID CSF, a clear and colorless fluid with a specific gravity of 1.007, is produced in the ventricles and is circulated around the brain and the spinal cord through the ventricular system. There are four ventricles: the right and left lateral, and the third and fourth ventricles. The two lateral ventricles open into the third ventricle at the interventricular foramen or the foramen of Monro. The third and fourth ventricles connect via the aqueduct of Sylvius. The fourth ventricle supplies CSF to the subarachnoid space and
Sagittal suture
Arachnoid villus Skin (cutis) Skull
Dura mater Meninges
Arachnoid Pia mater
Gray matter Brain tissue White matter
FIGURE 60-6 structures.
Meninges and related
Venous (dural) sinus
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down the spinal cord on the dorsal surface. CSF is returned to the brain and is then circulated around the brain, where it is absorbed by the arachnoid villi. CSF is produced in the choroid plexus of the lateral, third, and fourth ventricles. The ventricular and subarachnoid system contains approximately 125 to 150 mL of fluid, while 15 to 25 mL of CSF is located in each lateral ventricle. The composition of CSF is similar to other extracellular fluids (such as blood plasma), but the concentrations of the various constituents are different. The analysis and laboratory report of CSF usually contains information on color, specific gravity, protein count, white blood cell count, glucose, and other electrolyte levels; it may also be tested for immunoglobulins or lactate (Hickey, 2003). Normal CSF contains a minimal number of white blood cells and no red blood cells. CEREBRAL CIRCULATION The cerebral circulation receives approximately 15% of the cardiac output, or 750 mL per minute. The brain does not store nutrients and has a high metabolic demand that requires the high blood flow. The brain’s blood pathway is unique because it flows against gravity; its arteries fill from below and the veins drain from above. In contrast to other organs that may tolerate decreases in blood flow because of their adequate collateral circulation, the brain lacks additional collateral blood flow, which may result in irreversible tissue damage when blood flow is occluded for even short periods of time. Arteries. Two internal carotid arteries and two vertebral arteries and their extensive system of branches provide the blood supply to the brain. The internal carotids arise from the bifurcation of the common carotid and supply much of the anterior circulation of the brain. The vertebral arteries branch from the subclavian arteries, flow back and upward on either side of the cervical vertebrae, and enter the cranium through the foramen magnum. The vertebral arteries join to become the basilar artery at the level of the brain stem; the basilar artery divides to form the two branches of the posterior cerebral arteries. The vertebrobasilar arteries supply most of the posterior circulation of the brain.
At the base of the brain surrounding the pituitary gland, a ring of arteries is formed between the vertebral and internal carotid arterial chains. This ring is called the circle of Willis and is formed from the branches of the internal carotid arteries, anterior and middle cerebral arteries, and anterior and posterior communicating arteries (Fig. 60-7). Functionally, the posterior portion of the circulation and the anterior or carotid circulation usually remain separate. The arteries of the circle of Willis can provide collateral circulation if one or more of the four vessels supplying it become occluded or are ligated. The arterial anastomoses along the circle of Willis are frequent sites of aneurysms. These can be formed when the pressure at a weakened arterial wall causes the artery to balloon out. Aneurysms may be congenital or the result of degenerative changes in the vessel wall associated with arteriosclerotic vascular disease. If an artery with an aneurysm bursts or becomes occluded by vasospasm, an embolus, or a thrombus, the neurons distal to the occlusion are deprived of their blood supply and the cells quickly die. The result is a hemorrhagic stroke (cerebrovascular accident or infarction). The effects of the occlusion depend on which vessels are involved and which areas of the brain these vessels supply. Aneurysms and cerebrovascular accidents are discussed in more detail in Chapter 62. Veins. Venous drainage for the brain does not follow the arterial circulation as in other body structures. The veins reach the brain’s surface, join larger veins, then cross the subarachnoid space and empty into the dural sinuses, which are the vascular channels lying within the tough dura mater (see Fig. 60-6). The network of the sinuses carries venous outflow from the brain and empties into the internal jugular vein, returning the blood to the heart. Cerebral veins and sinuses are unique because, unlike other veins in the body, they do not have valves to prevent blood from flowing backward and depend on both gravity and blood pressure. BLOOD–BRAIN BARRIER The CNS is inaccessible to many substances that circulate in the blood plasma (eg, dyes, medications, and antibiotics). After being injected into the blood, many substances cannot reach the neu-
Middle cerebral artery Anterior cerebral artery Anterior communicating artery Internal carotid artery Posterior communicating artery Posterior cerebral artery
Circle of Willis
Basilar artery Vertebral artery Anterior spinal artery
FIGURE 60-7 Arterial blood supply of the brain, including the circle of Willis, as viewed from the ventral surface.
Chapter 60 rons of the CNS because of the blood–brain barrier. This barrier is formed by the endothelial cells of the brain’s capillaries, which form continuous tight junctions, creating a barrier to macromolecules and many compounds. All substances entering the CSF must filter through the capillary endothelial cells and astrocytes (Hickey, 2003). Often altered by trauma, cerebral edema, and cerebral hypoxemia, the blood–brain barrier has implications in the treatment and selection of medication for CNS disorders as well as serving a protective function. ANATOMY OF THE SPINAL CORD The spinal cord and medulla form a continuous structure extending from the cerebral hemispheres and serving as the connection between the brain and the periphery. Approximately 45 cm (18 in) long and about the thickness of a finger, it extends from the foramen magnum at the base of the skull to the lower border of the first lumbar vertebra, where it tapers to a fibrous band called the conus medullaris. Continuing below the second lumbar space are the nerve roots that extend beyond the conus, which are called the cauda equina because they resemble a horse’s tail. Similar to the brain, the spinal cord consists of gray and white matter. Gray matter in the brain is external and white matter is internal; in the spinal cord, gray matter is in the center and is surrounded on all sides by white matter (Fig. 60-8). The spinal cord is surrounded by the meninges, dura, arachnoid, and pia layers. Between the dura mater and the vertebral canal is the epidural space. The spinal cord is an H-shaped structure with nerve cell bodies (gray matter) surrounded by ascending and descending tracts (white matter) (see Fig. 60-8). The lower portion of the H is broader than the upper portion and corresponds to the anterior horns. The anterior horns contain cells with fibers that form the anterior (motor) root end and are essential for the voluntary and reflex activity of the muscles they innervate. The thinner posterior (upper horns) portion contains cells with fibers that enter over the posterior (sensory) root end and thus serve as a relay station in the sensory/reflex pathway. The thoracic region of the spinal cord has a projection from each side at the crossbar of the H of gray matter called the lateral horn. It contains the cells that give rise to the autonomic fibers of the sympathetic division. The fibers leave the spinal cord through the anterior roots in the thoracic and upper lumbar segments.
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Sensory and Motor Pathways: The Spinal Tracts. The white matter of the cord is composed of myelinated and unmyelinated nerve fibers. The fast-conducting myelinated fibers form bundles that also contain glial cells. Fiber bundles with a common function are called tracts. There are six ascending tracts. Two conduct sensation, principally the perception of touch, pressure, vibration, position, and passive motion from the same side of the body. Before reaching the cerebral cortex, these fibers cross to the opposite side in the medulla. The two spinocerebellar tracts conduct sensory impulses from muscle spindles, providing necessary input for coordinated muscle contraction. They ascend essentially uncrossed and terminate in the cerebellum. The last two spinothalamic tracts are responsible for conduction of pain, temperature, proprioception, fine touch, and vibratory sense from the upper body to the brain. They ascend, cross to the opposite side of the brain, and terminate in the thalamus (Hickey, 2003). There are eight descending tracts, seven of which are engaged in motor function. The two corticospinal tracts conduct motor impulses to the anterior horn cells from the opposite side of the brain and control voluntary muscle activity. The three vestibulospinal tracts descend uncrossed and are involved in some autonomic functions (sweating, pupil dilation, and circulation) and involuntary muscle control. The corticobulbar tract conducts impulses responsible for voluntary head and facial muscle movement and crosses at the level of the brain stem. The rubrospinal and reticulospinal tracts conduct impulses involved with involuntary muscle movement. Vertebral Column. The bones of the vertebral column surround and protect the spinal cord and normally consist of 7 cervical, 12 thoracic, and 5 lumber vertebrae, as well as the sacrum (a fused mass of five vertebrae), and terminate in the coccyx. Nerve roots exit from the vertebral column through the intervertebral foramina (openings). The vertebrae are separated by disks, except for the first and second cervical, the sacral, and the coccygeal vertebrae. Each vertebra has a ventral solid body and a dorsal segment or arch, which is posterior to the body. The arch is composed of two pedicles and two laminae supporting seven processes. The vertebral body, arch, pedicles, and laminae all encase the vertebral canal.
White matter
Fasciculus gracilis Fasciculus cuneatus Posterior spinocerebellar Lateral corticospinal
Rubrospinal
Anterior spinocerebellar
Lateral spinothalamic
Anterior corticospinal
FIGURE 60-8
Cross-sectional diagram of the spinal cord showing major spinal tracts.
Anterior spinothalamic Descending fibers
Tectospinal Vestibulospinal Ascending fibers
Gray matter
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The Peripheral Nervous System The peripheral nervous system includes the cranial nerves, the spinal nerves, and the autonomic nervous system. CRANIAL NERVES There are 12 pairs of cranial nerves that emerge from the lower surface of the brain and pass through the foramina in the skull. Three are entirely sensory (I, II, VIII), five are motor (III, IV, VI, XI, and XII), and four are mixed (V, VII, IX, and X) as they have both sensory and motor functions (Downey & Leigh, 1998; Hickey, 2003). The cranial nerves are numbered in the order in which they arise from the brain. For example, cranial nerves I and II attach in the cerebral hemispheres, whereas cranial nerves IX, X, XI, and XII attach at the medulla (Fig. 60-9). Most cranial nerves innervate the head, neck, and special sense structures. Table 60-2 lists the names and primary functions of the cranial nerves. SPINAL NERVES The spinal cord is composed of 31 pairs of spinal nerves: 8 cervical, 12 thoracic, 5 lumbar, 5 sacral, and 1 coccygeal. Each spinal nerve has a ventral root and a dorsal root (Fig. 60-10). The dorsal roots are sensory and transmit sensory impulses from specific areas of the body known as dermatomes (Fig. 60-11) to the dorsal ganglia. The sensory fiber may be somatic, carrying information about pain, temperature, touch, and position sense (proprioception) from the tendons, joints, and body surfaces; or visceral, carrying information from the internal organs. The ventral roots are motor and transmit impulses from the spinal cord to the body. These fibers are also either somatic or visceral. The visceral fibers include autonomic fibers that control the cardiac muscles and glandular secretions. AUTONOMIC NERVOUS SYSTEM The autonomic nervous system regulates the activities of internal organs such as the heart, lungs, blood vessels, digestive organs, and glands. Maintenance and restoration of internal homeostasis is largely the responsibility of the autonomic nervous system. There are two major divisions: the sympathetic nervous system,
Table 60-2 CRANIAL NERVE
TYPE
FUNCTION
I (olfactory) II (optic) III (oculomotor)
Sensory Sensory Motor
IV (trochlear) V (trigeminal)
Motor Mixed
VI (abducens) VII (facial)
Motor Mixed
VIII (acoustic) IX (glossopharyngeal)
Sensory Mixed
X (vagus)
Mixed
XI (spinal accessory)
Motor
XII (hypoglossal)
Motor
Sense of smell Visual acuity Muscles that move the eye and lid, pupillary constriction, lens accommodation Muscles that move the eye Facial sensation, corneal reflex, mastication Muscles that move the eye Facial expression and muscle movement, salivation and tearing, taste, sensation in the ear Hearing and equilibrium Taste, sensation in pharynx and tongue, pharyngeal muscles Muscles of pharynx, larynx, and soft palate; sensation in external ear, pharynx, larynx, thoracic and abdominal viscera; parasympathetic innervation of thoracic and abdominal organs Sternocleidomastoid and trapezius muscles Movement of the tongue
with predominantly excitatory responses, most notably the “fight or flight” response, and the parasympathetic nervous system, which controls mostly visceral functions. The autonomic nervous system innervates most body organs. Although usually considered part of the peripheral nervous system, it is regulated by centers in the spinal cord, brain stem, and
Name Optic II
• Cranial Nerves
Location
Cerebral hemisphere
Olfactory I Oculomotor III Midbrain Trochlear IV Trigeminal V Abducens VI Pons Facial VII Acoustic VIII Glossopharyngeal IX Vagus X Medulla Hypoglossal XII Spinal accessory XI
FIGURE 60-9
Diagram of the base of the brain showing entrance or exit of the cranial nerves. The right column shows the anatomic location of the connection of each cranial nerve to the central nervous system.
Chapter 60 Ventral root (efferent/motor)
Dorsal root (afferent/sensory)
Gray matter Spinal cord
FIGURE 60-10 Cross-section of the spinal cord showing dorsal and ventral roots of a spinal nerve. hypothalamus. The autonomic nervous system has two neurons in a series extending between the centers in the CNS and the organs innervated. The first neuron, the preganglionic neuron, is located in the brain or spinal cord, and its axon extends to the autonomic ganglia. There, it synapses with the second neuron, the postganglionic neuron, located in the autonomic ganglia, and its axon synapses with the target tissue and innervates the effector
C2 C3 C4 C5 C6 C7 C8 T1 T2 T3 T4 T5 T6
C2 C3 C4 C5 T1 T2 T3 T4 T5 T6 T7 T8 T9 T10
T1
C8
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organ. Its regulatory effects are exerted not on individual cells but on large expanses of tissue and on entire organs. The responses elicited do not occur instantaneously but after a lag period. These responses are sustained far longer than other neurogenic responses to ensure maximal functional efficiency on the part of receptor organs, such as blood vessels. The quality of these responses is explained by the fact that the autonomic nervous system transmits its impulses by way of nerve pathways, enhanced by chemical mediators, resembling in this respect the endocrine system. Electrical impulses, conducted through nerve fibers, stimulate the formation of specific chemical agents at strategic locations within the muscle mass; the diffusion of these chemicals within the muscle is responsible for the contraction. The hypothalamus is the major subcortical center for the regulation of visceral and somatic activities, with an inhibitory– excitatory role in the autonomic nervous system. The hypothalamus has connections that link the autonomic system with the thalamus, the cortex, the olfactory apparatus, and the pituitary gland. Located here are the mechanisms for the control of visceral and somatic reactions that were originally important for defense or attack, and are associated with emotional states (eg, fear, anger, anxiety); for the control of metabolic processes, including fat, carbohydrate, and water metabolism; for the regulation of body temperature, arterial pressure, and all muscular and glandular activities of the gastrointestinal tract; for control of genital functions; and for the sleep cycle.
White matter
To skin (sensory) and skeletal muscle (motor)
Spinal nerve root
Assessment of Neurologic Function
T7 T8 T9 T 10 T 11
C5
T 12
L1 L2 L3 L4 L5 S1 S2 S3 S4
T11 T12 L1 L2
C8
L3
S2 S1 L5 S2
L4
L5 S1 S1
FIGURE 60-11 bution.
Dermatome distri-
L4
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The autonomic nervous system is separated into the anatomically and functionally distinct sympathetic and parasympathetic divisions. Most of the tissues and the organs under autonomic control are innervated by both systems. Sympathetic stimuli are mediated by norepinephrine and parasympathetic impulses are mediated by acetylcholine. These chemicals produce opposing and mutually antagonistic effects. Both divisions produce stimulatory and inhibitory effects. For example, the parasympathetic division causes contraction (stimulation) of the urinary bladder muscles and a decrease (inhibition) in heart rate, whereas the sympathetic division produces relaxation (inhibition) of the urinary bladder and an increase (stimulation) in the rate and force of the heartbeat. Table 60-3 compares the sympathetic and the parasympathetic effects on the different systems of the body. Sympathetic Nervous System. The sympathetic division of the autonomic nervous system is best known for its role in the body’s “fight-or-flight” response. Under stress conditions from either physical or emotional causes, sympathetic impulses increase greatly. As a result, the bronchioles dilate for easier gas exchange; the heart’s contractions are stronger and faster; the arteries to the heart and voluntary muscles dilate, carrying more blood to these organs; peripheral blood vessels constrict, making the skin feel cool but shunting blood to essential organs; the pupils dilate; the liver releases glucose for quick energy; peristalsis slows; hair stands on end; and perspiration increases. The sympathetic neurotransmitter is norepinephrine (noradrenaline), and this increase in sympathetic discharge is the same as if the body has been given an injection of adrenalin—hence, the term adrenergic is often used to refer to this division. Sympathetic neurons are located in the thoracic and the lumbar segments of the spinal cord; their axons, or the preganglionic fibers, emerge by way of anterior nerve roots from the eighth cervical or first thoracic segment to the second or third lumbar segment. A short distance from the cord, these fibers diverge to join a chain, composed of 22 linked ganglia, that extends the entire length of the spinal column, adjacent to the vertebral bodies on both sides. Some form multiple synapses with nerve cells within the chain. Others traverse the chain without making connections or losing continuity to join large “prevertebral” ganglia in the thorax, the abdomen, or the pelvis or one of the “terminal” ganglia in the vicinity of an organ, such as the bladder or the rectum (Fig. 60-12). Postganglionic nerve fibers originating in the sympathetic chain rejoin the spinal nerves that supply the extremities and are distributed to blood vessels, sweat glands, and smooth muscle tissue in the skin. Postganglionic fibers from the prevertebral plexuses (eg, the cardiac, pulmonary, splanchnic, and pelvic plexuses) supply structures in the head and neck, thorax, abdomen, and pelvis, respectively, having been joined in these plexuses by fibers from the parasympathetic division. The adrenal glands, kidneys, liver, spleen, stomach, and duodenum are under the control of the giant celiac plexus, commonly known as the solar plexus. This receives its sympathetic nerve components by way of the three splanchnic nerves, composed of preganglionic fibers from nine segments of the spinal cord (T4 to L1), and is joined by the vagus nerve, representing the parasympathetic division. From the celiac plexus, fibers of both divisions travel along the course of blood vessels to their target organs.
absence of peristaltic waves and the distention of the intestine by gas) after fracture of any one of the lower dorsal or upper lumbar vertebrae with hemorrhage into the base of the mesentery; and the marked variations in pulse rate and rhythm that often follow compression fractures of the upper six thoracic vertebrae.
Sympathetic Syndromes. Certain syndromes are distinctive to diseases of the sympathetic nerve trunks. Among these are dilation of the pupil of the eye on the same side as a penetrating wound of the neck (evidence of disturbance of the cervical sympathetic cord); temporary paralysis of the bowel (indicated by the
Parasympathetic Nervous System. The parasympathetic nervous system functions as the dominant controller for most visceral effectors. During quiet, nonstressful conditions, impulses from parasympathetic fibers (cholinergic) predominate. The fibers of the parasympathetic system are located in two sections, one in the
Chapter 60 Brain stem and spinal cord
Assessment of Neurologic Function
Sympathetic chain
Nerves and ganglia
Oculomotor n.
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Organs Eye
Facial n.
Lacrimal gland
Glossopharyngeal n.
Parotid gland Salivary gland Larynx
Vagus n.
Lungs
Heart Stomach Celiac ganglion and plexus
Liver Pancreas
Superior mesenteric ganglion Inf. mesenteric ganglion and plexus
Adrenal gland Kidney Intestine
Colon
Bladder
FIGURE 60-12 Anatomy of the autonomic nervous system. brain stem and the other from spinal segments below L2. Because of the location of these fibers, the parasympathetic system is referred to as the craniosacral division, as distinct from the thoracolumbar (sympathetic) division of the autonomic nervous system. The parasympathetic nerves arise from the midbrain and the medulla oblongata. Fibers from cells in the midbrain travel with the third oculomotor nerve to the ciliary ganglia, where postganglionic fibers of this division are joined by those of the sympathetic system, creating controlled opposition, with a delicate balance maintained between the two at all times.
Motor and Sensory Functions of the Nervous System MOTOR SYSTEM FUNCTION The motor cortex, a vertical band within each cerebral hemisphere, controls the voluntary movements of the body. The exact locations within the brain at which the voluntary movements of the muscles of the face, thumb, hand, arm, trunk, and leg originate are known (Fig. 60-13). To initiate muscle movement, these particular cells must send the stimulus down along their fibers. Stimulation of these cells with an electric current will also result in muscle contraction. En route to the pons, the motor fibers con-
Pelvic n.
Reproductive organs
verge into a tight bundle known as the internal capsule. A comparatively small injury to the capsule causes paralysis in more muscles than does a much larger injury to the cortex itself. Within the medulla, the motor axons from the cortex form the motor pathways or tracts, notably the corticospinal or pyramidal tracts. Here, most of the fibers cross (or decussate) to the opposite side, continuing as a crossed pyramidal tract. The remaining fibers enter the spinal cord on the same side as the direct pyramidal tract. Each fiber in this tract finally crosses to the opposite side of the cord and terminates within the gray matter of the anterior horn on that side, in proximity to a motor nerve cell. Fibers of the crossed pyramidal tract terminate within the anterior horn and make connections with anterior horn cells on the same side. All of the motor fibers of the spinal nerves represent extensions of these anterior horn cells, with each of these fibers communicating with only one particular muscle fiber. The motor system is complex, and motor function depends on the integrity of the corticospinal tracts, the extrapyramidal system, and cerebellar function. A motor impulse consists of a two-neuron pathway (described below). The motor nerve pathways are contained in the spinal cord. Some represent the pathways of the so-called extrapyramidal system, establishing connections between the anterior horn cells and the automatic control centers located in the basal ganglia and the cerebellum. Others are
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Wrist
Trunk Hip
Elbow and arm
Thigh Knee Leg
Hand and fingers Face and neck
Foot and ankle
Tongue
FIGURE 60-13 Diagrammatic representation of the cerebrum showing locations for control of motor movement of various parts of the body.
Larynx
components of reflex arcs, forming synaptic connections between anterior horn cells and sensory fibers that have entered adjacent or neighboring segments of the cord. Upper and Lower Motor Neurons. The voluntary motor system consists of two groups of neurons: upper motor neurons and lower motor neurons. Upper motor neurons originate in the cerebral cortex, the cerebellum, and the brain stem and modulate the activity of the lower motor neurons. Upper motor neuron fibers make up the descending motor pathways and are located entirely within the CNS. Lower motor neurons are located either in the anterior horn of the spinal cord gray matter or within cranial nerve nuclei in the brain stem. Axons of both extend through peripheral nerves and terminate in skeletal muscle. Lower motor neurons are located in both the CNS and the peripheral nervous system. The motor pathways from the brain to the spinal cord, as well as from the cerebrum to the brain stem, are formed by upper motor neurons. They begin in the cortex of one side of the brain, descend through the internal capsule, cross to the opposite side in the brain stem, descend through the corticospinal tract, and synapse with the lower motor neurons in the cord. The lower motor neurons receive the impulse in the posterior part of the cord and run to the myoneural junction located in the peripheral muscle. The clinical features of lesions of upper and lower motor neurons are discussed in the sections that follow and in Table 60-4. Upper Motor Neuron Lesions. Upper motor neuron lesions can involve the motor cortex, the internal capsule, the spinal cord, and other structures of the brain through which the corticospinal tract descends. If the upper motor neurons are damaged or destroyed, as frequently occurs with stroke or spinal cord injury, paralysis (loss of voluntary movement) results. However, because the inhibitory influences of intact upper motor neurons are now impaired, reflex (involuntary) movements are uninhibited, and
hence hyperactive deep tendon reflexes, diminished or absent superficial reflexes, and pathologic reflexes such as a Babinski response occur. Severe leg spasms can occur as the result of an upper motor neuron lesion; the spasms result from the preserved reflex arc, which lacks inhibition along the spinal cord below the level of injury. There is little or no muscle atrophy, and muscles remain permanently tense, exhibiting spastic paralysis or paresis (weakness). Paralysis associated with upper motor neuron lesions usually affects a whole extremity, both extremities, and an entire half of the body. Hemiplegia (paralysis of an arm and leg on the same side of the body) can be the result of an upper motor neuron lesion. If hemorrhage, an embolus, or a thrombus destroys the fibers from the motor area in the internal capsule, the arm and the leg of the opposite side become stiff and very weak or paralyzed, and the reflexes are hyperactive (further discussion of hemiplegia is found in Chap. 62). When both legs are paralyzed, the condition is called paraplegia; paralysis of all four extremities is quadriplegia (more discussion of these can be found in Chap. 63). Lower Motor Neuron Lesions. A patient is considered to have lower motor neuron damage if a motor nerve is severed between
Table 60-4
• Comparison of Upper Motor Neuron and Lower Motor Neuron Lesions
UPPER MOTOR NEURON LESIONS
LOWER MOTOR NEURON LESIONS
Loss of voluntary control Increased muscle tone Muscle spasticity No muscle atrophy Hyperactive and abnormal reflexes
Loss of voluntary control Decreased muscle tone Flaccid muscle paralysis Muscle atrophy Absent or decreased reflexes
Chapter 60 the muscle and the spinal cord. The result of lower motor neuron damage is muscle paralysis. Reflexes are lost, and the muscle becomes flaccid (limp) and atrophied from disuse. If the patient has injured the spinal trunk and it can heal, use of the muscles connected to that section of the spinal cord may be regained. If the anterior horn motor cells are destroyed, however, the nerves cannot regenerate and the muscles are never useful again. Flaccid paralysis and atrophy of the affected muscles are the principal signs of lower motor neuron disease. Lower motor neuron lesions can be the result of trauma, infection (poliomyelitis), toxins, vascular disorders, congenital malformations, degenerative processes, and neoplasms. Compression of nerve roots by herniated intervertebral disks is a common cause of lower motor neuron dysfunction. Coordination of Movement. The smoothness, accuracy, and strength that characterize the muscular movements of a normal person are attributable to the influence of the cerebellum and the basal ganglia. The cerebellum (refer to Fig. 60-2), described earlier, is located beneath the occipital lobe of the cerebrum; it is responsible for the coordination, balance, and timing of all muscular movements that originate in the motor centers of the cerebral cortex. Through the action of the cerebellum, the contractions of opposing muscle groups are adjusted in relation to each other to maximal mechanical advantage; muscle contractions can be sustained evenly at the desired tension and without significant fluctuation, and reciprocal movements can be reproduced at high and constant speed, in stereotyped fashion and with relatively little effort. The basal ganglia, masses of gray matter in the midbrain beneath the cerebral hemispheres, border the lateral ventricles and lie in proximity to the internal capsule. The basal ganglia play an important role in planning and coordinating motor movements and posture. Complex neural connections link the basal ganglia with the cerebral cortex. The major effect of these structures is to inhibit unwanted muscular activity; disorders of the basal ganglia result in exaggerated, uncontrolled movements. Impaired cerebellar function, which may occur as a result of an intracranial injury or some type of an expanding mass (eg, a hemorrhage, abscess, or tumor), results in loss of muscle tone, weakness, and fatigue. Depending on the area of the brain affected, the patient has different motor symptoms or responses. The patient may demonstrate decorticate, decerebrate, or flaccid posturing, usually as a result of cerebral trauma (Bateman, 2001). For further explanation of this, see Figure 61-1 in Chapter 61. Decortication (decorticate posturing) is the result of lesions of the internal capsule or cerebral hemispheres; the patient has flexion and internal rotation of the arms and wrists and extension, internal rotation, and plantar flexion of the feet. Decerebration (decerebrate posturing), the result of lesions at the midbrain, is more ominous than decortication. The patient has extension and external rotation of the arms and wrists and extension, plantar flexion, and internal rotation of the feet. Flaccid posturing is usually the result of lower brain stem dysfunction; the patient has no motor function, is limp, and lacks motor tone. Flaccidity preceded by decerebration in a patient with cerebral injury indicates severe neurologic impairment, which may herald brain death. However, before the declaration of brain death, the patient must have spinal cord injury ruled out, the effects of all neuromuscular paralyzing agents must have worn off, and any other possible treatable causes of neurologic impairment must be investigated.
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Tumors, infection, or abscess and increased intracranial pressure can all affect the cerebellum. Cerebellar signs, such as ataxia, incoordination, and seizures, as well as CSF obstruction and compression of the brain stem may be seen. Signs of increased intracranial pressure, including vomiting, headache, and changes in vital signs and level of consciousness, are especially common when CSF flow is obstructed. Destruction or dysfunction of the basal ganglia leads not to paralysis but to muscle rigidity, with disturbances of posture and movement. Such patients tend to have involuntary movements. These may take the form of coarse tremors, most often in the upper extremities, particularly in the distal portions; athetosis, movement of a slow, squirming, writhing, twisting type; or chorea, marked by spasmodic, purposeless, irregular, uncoordinated motions of the trunk and the extremities, and facial grimacing. Disorders due to lesions of the basal ganglia include Parkinson’s disease, Huntington’s disease (see Chap. 65), and spasmodic torticollis. SENSORY SYSTEM FUNCTION Integrating Sensory Impulses. The thalamus, a major receiving and transmitting center for the afferent sensory nerves, is a large structure connected to the midbrain. It lies next to the third ventricle and forms the floor of the lateral ventricle (see Fig. 60-3). The thalamus integrates all sensory impulses except olfaction. It plays a role in the conscious awareness of pain and the recognition of variation in temperature and touch. The thalamus is responsible for the sense of movement and position and the ability to recognize the size, shape, and quality of objects. Receiving Sensory Impulses. Afferent impulses travel from their points of origin to their destinations in the cerebral cortex via the ascending pathways directly, or they may cross at the level of the spinal cord or in the medulla, depending on the type of sensation that is registered. Sensory information may be integrated at the level of the spinal cord or may be relayed to the brain. Knowledge of these pathways is important for neurologic assessment and for understanding symptoms and their relationship to various lesions. Sensory impulses enter the spinal cord by way of the posterior root. These axons convey sensations of heat, cold, and pain and enter the posterior gray column of the cord, where they make connections with the cells of secondary neurons. Pain and temperature fibers cross immediately to the opposite side of the cord and course upward to the thalamus. Fibers carrying sensations of touch, light pressure, and localization do not connect immediately with the second neuron but ascend the cord for a variable distance before entering the gray matter and completing this connection. The axon of the secondary neuron crosses the cord and proceeds upward to the thalamus. Position and vibratory sensation are produced by stimuli arising from muscles, joints, and bones. These stimuli are conveyed, uncrossed, all the way to the brain stem by the axon of the primary neuron. In the medulla, synaptic connections are made with cells of the secondary neurons, whose axons cross to the opposite side and then proceed to the thalamus. Sensory Losses. Destruction of a sensory nerve results in total loss of sensation in its area of distribution. Transection of the spinal cord yields complete anesthesia below the level of injury. Selective destruction or degeneration of the posterior columns of the spinal cord is responsible for a loss of position and vibratory sense in segments distal to the lesion, without loss of touch, pain, or temperature perception. A lesion, such as a cyst, in the center of the spinal cord causes dissociation of sensation—loss of pain
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NEUROLOGIC FUNCTION
at the level of the lesion. This occurs because the fibers carrying pain and temperature cross within the cord immediately on entering; thus, any lesion that divides the cord longitudinally divides these fibers. Other sensory fibers ascend the cord for variable distances, some even to the medulla, before crossing, thereby bypassing the lesion and avoiding destruction. Lesions affecting the posterior spinal nerve roots may cause impairment of tactile sensation, including intermittent severe pain that is referred to their areas of distribution. Tingling of the fingers and the toes can be a prominent symptom of spinal cord disease, presumably due to degenerative changes in the sensory fibers that extend to the thalamus (ie, belonging to the spinothalamic tract).
Assessment: The Neurologic Examination HEALTH HISTORY An important aspect of the neurologic assessment is the history of the present illness. The initial interview provides an excellent opportunity to systematically explore the patient’s current condition and related events while simultaneously observing overall appearance, mental status, posture, movement and affect. Depending on the patient’s condition, the nurse may need to rely on yes-or-no answers to questions, on a review of the medical record, or input from the family or a combination of these.
Neurologic disease may be stable or progressive, with both intermittent symptom-free periods as well as times with fluctuations in symptoms. The health history therefore includes details about the onset, character, severity, location, duration, and frequency of symptoms and signs; associated complaints; precipitating, aggravating, and relieving factors; progression, remission, and exacerbation; and the presence or absence of similar symptoms among family members. The nurse may also use the interview to inquire about any family history of genetic diseases. See the Genetics chart for assessment guidelines and Chapter 9 for additional information about genetics. Included in the health history is a review of the medical history, including a system-by-system evaluation. The nurse should be aware of any history of trauma or falls that may have involved the head or spinal cord. Questions regarding the use of alcohol, medications, and recreational drugs are also included. The historytaking portion of the neurologic examination is critical and, in many cases of neurologic disease, leads to an accurate diagnosis.
CLINICAL MANIFESTATIONS The clinical manifestations of neurologic disease are as varied as the disease processes themselves. Symptoms can be subtle or intense, fluctuating or permanent, an inconvenience or devastating. An introduction to some of the most common symptoms associ-
GENETICS IN NURSING PRACTICE—Neurologic Disorders DISEASES AND CONDITIONS INFLUENCED BY GENETIC FACTORS • Alzheimer’s disease • Amyotrophic lateral sclerosis (ALS) • Duchenne muscular dystrophy • Epilepsy • Friedrich ataxia • Huntington disease • Myotonic dystrophy • Neurofibromatosis type I • Parkinson’s disease • Spina bifida • Tourette syndrome NURSING ASSESSMENTS
MANAGEMENT SPECIFIC TO GENETICS • Inquire whether DNA mutation or other genetic testing has been performed on affected family members. • If indicated, refer for further genetic counseling and evaluation so that family members can discuss inheritance, risk to other family members, availability of genetic testing and gene-based interventions. • Offer appropriate genetics information and resources. • Assess patient’s understanding of genetics information. • Provide support to families with newly diagnosed geneticrelated neurologic disorders. • Participate in management and coordination of care of patients with genetic conditions and individuals predisposed to develop or pass on a genetic condition.
FAMILY HISTORY ASSESSMENT
• Assess for other similarly affected relatives with neurologic impairment.
• Inquire about age of onset (eg, present at birth—spina bifida;
•
developed in childhood—Duchenne muscular dystrophy; developed in adulthood—Huntington disease, Alzheimer’s disease, amyotrophic lateral sclerosis) Inquire about the presence of related conditions such as mental retardation and/or learning disabilities (neurofibromatosis type I).
PHYSICAL ASSESSMENT
• Assess for the presence of other physical features suggestive of •
an underlying genetic condition, such as skin lesions seen in neurofibromatosis type 1 (café-au-lait spots). Assess for other congenital abnormalities (eg, cardiac, ocular).
GENETICS RESOURCES FOR NURSES AND THEIR PATIENTS ON THE WEB Genetic Alliance: http://www.geneticalliance.org—a directory of support groups for patients and families with genetic conditions Gene Clinics: http://www.geneclinics.org—a listing of common genetic disorders with up-to-date clinical summaries, genetic counseling and testing information National Organization of Rare Disorders: http://www. rarediseases.org—a directory of support groups and information for patients and families with rare genetic disorders OMIM: Online Mendelian Inheritance in Man: http://www. nchi.nlm.nih.gov/omim/stats/html—a complete listing of inherited genetic conditions
Chapter 60
Assessment of Neurologic Function
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ated with neurologic disease follows; detailed discussions regarding how specific symptoms relate to a particular disorder will be covered in later chapters in this unit.
wide range of disability. Weakness can be sudden and permanent, as in stroke, or progressive, as in many neuromuscular diseases such as amyotrophic lateral sclerosis. Any muscle group can be affected.
Pain
Abnormal Sensation
Pain is considered an unpleasant sensory perception and emotional experience associated with actual or potential tissue damage or described in terms of such damage. Pain is therefore considered multidimensional and entirely subjective (Loeser, 2001). Pain can be acute or chronic. In general, acute pain lasts for a relatively short period of time and remits as the pathology resolves. In neurologic disease, this type of pain is often associated with spinal disc disease, trigeminal neuralgia, or other neuropathic pathology (eg, postherpetic neuralgia, or painful neuropathies). In contrast, chronic pain extends for long periods of time and may represent a low level of pathology. This type of pain might also occur with discogenic disease.
Numbness, abnormal sensation, or loss of sensation is a neurologic manifestation of both central and peripheral nervous system disease. Altered sensation can affect small or large areas of the body. It is frequently associated with weakness or pain and is potentially disabling. Both numbness and weakness can significantly affect balance and coordination.
Seizures Seizures are the result of abnormal paroxysmal discharges in the cerebral cortex, which then manifest as an alteration in sensation, behavior, movement, perception, or consciousness (Hickey, 2003). The alteration may be short, as in a blank stare lasting only a second, or of longer duration, such as a tonic-clonic grand mal seizure that can last several minutes. The type of seizure activity is a direct result of the area of the brain affected. Seizures can occur as isolated events, such as when induced by a high fever, alcohol or drug withdrawal, or hypoglycemia. A seizure may also be the first obvious sign of a brain lesion.
Dizziness Dizziness is an abnormal sensation of imbalance or movement. It is fairly common in the elderly and one of the most common complaints encountered by health professionals. Dizziness can have a variety of causes, including viral syndromes, hot weather, roller coaster rides, and middle ear infections, to name a few. One difficulty confronting health care providers when assessing dizziness is the vague and varied terms patients use to describe the sensation. Vertigo, a specific form of dizziness, is defined as a sensation that is usually a manifestation of vestibular dysfunction. It can be so severe as to result in spatial disorientation, loss of equilibrium, and nausea and vomiting (Greenberg, Aminoff, & Simon, 2002).
PHYSICAL EXAMINATION The neurologic examination is a systematic process that includes a variety of clinical tests, observations, and assessments designed to evaluate a complex system. Although the neurologic examination is often limited to a simple screening, the examiner must be able to conduct a thorough neurologic assessment when the patient’s history or other physical findings warrant it. Many neurologic rating scales exist; some of the more common ones are discussed here, but an in-depth discussion is beyond the scope of this chapter (see Herndon [1997] and Rapp, Wakefield, Kundrat et al. [2000] for full descriptions of neurologic rating scales). The brain and spinal cord cannot be examined as directly as other systems of the body. Thus, much of the neurologic examination is an indirect evaluation that assesses the function of the specific body part or parts controlled or innervated by the nervous system. A neurologic assessment is divided into five components: cerebral function, cranial nerves, motor system, sensory system, and reflexes. As in other parts of the physical assessment, the neurologic examination follows a logical sequence and progresses from higher levels of cortical function such as abstract thinking to lower levels of function such as the determination of the integrity of peripheral nerves.
Assessing Cerebral Function Cerebral abnormalities may cause disturbances in mental status, intellectual functioning, and thought content and in patterns of emotional behavior. There may also be alterations in perception, motor and language abilities, as well as lifestyle.
Weakness
MENTAL STATUS An assessment of mental status begins by observing the patient’s appearance and behavior, noting dress, grooming, and personal hygiene. Posture, gestures, movements, facial expressions, and motor activity often provide important information about the patient. The patient’s manner of speech and level of consciousness are also assessed. Is the patient’s speech clear and coherent? Is the patient alert and responsive, or drowsy and stuporous? Assessing orientation to time, place, and person assists in evaluating mental status. Does the patient know what day it is, what year it is, and the name of the president of the United States? Is the patient aware of where he or she is? Is the patient aware of who the examiner is and of his or her purpose for being in the room? Is the capacity for immediate memory intact? (See Chart 12-1: Mini-Mental State Examination in Chap. 12.)
Weakness, specifically muscle weakness, is a common manifestation of neurologic disease. Weakness frequently coexists with other symptoms of disease and can affect a variety of muscles, causing a
INTELLECTUAL FUNCTION A person with an average IQ can repeat seven digits without faltering and can recite five digits backward. The examiner might
Visual Disturbances Visual defects that cause people to seek health care can range from the decreased visual acuity associated with aging to sudden blindness caused by glaucoma. Normal vision depends upon functioning visual pathways through the retina and optic chiasm and the radiations into the visual cortex in the occipital lobes. Lesions of the eye itself (eg, cataract), lesions along the pathway (eg, tumor), or lesions in the visual cortex (from stroke) interfere with normal visual acuity. Abnormalities of eye movement (as in the nystagmus associated with multiple sclerosis) can also compromise vision by causing diplopia or double vision.
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ask the patient to count backward from 100 or to subtract 7 from 100, then 7 from that, and so forth (called serial 7s) ( Johnson, 2001). The capacity to interpret well-known proverbs tests abstract reasoning, which is a higher intellectual function; for example, does the patient know what is meant by “the early bird catches the worm”? Patients with damage to the frontal cortex appear superficially normal until one or more tests of integrative capacity are performed. Questions designed to assess this capacity might include the ability to recognize similarities: how are a mouse and dog or pen and pencil alike? Can the patient make judgements about situations—for instance, if the patient arrived home without a house key, what alternatives are there? THOUGHT CONTENT During the interview, it is important to assess the patient’s thought content. Are the patient’s thoughts spontaneous, natural, clear, relevant, and coherent? Does the patient have any fixed ideas, illusions, or preoccupations? What are his or her insights into these thoughts? Preoccupation with death or morbid events, hallucinations, and paranoid ideation are examples of unusual thoughts or perceptions that require further evaluation. EMOTIONAL STATUS An assessment of cerebral functioning also includes the patient’s emotional status. Is the patient’s affect (external manifestation of mood) natural and even, or irritable and angry, anxious, apathetic or flat, or euphoric? Does his or her mood fluctuate normally, or does the patient unpredictably swing from joy to sadness during the interview? Is affect appropriate to words and thought content? Are verbal communications consistent with nonverbal cues? PERCEPTION The examiner may now consider more specific areas of higher cortical function. Agnosia is the inability to interpret or recognize objects seen through the special senses. The patient may see a pencil but not know what it is called or what to do with it. The patient may even be able to describe it but not to interpret its function. The patient may experience auditory or tactile agnosia as well as visual agnosia. Each of the dysfunctions implicates a different part of the cortex (Chart 60-1). Screening for visual and tactile agnosia provides insight into the patient’s cortical interpretation ability. The patient is shown a familiar object and asked to identify it by name. Placing a familiar object (eg, key, coin) in the patient’s hand and having him or her identify it with both eyes closed is an easy way to assess tactile interpretation. MOTOR ABILITY Assessment of cortical motor integration is carried out by asking the patient to perform a skilled act (throw a ball, move a chair).
Chart 60-1
Successful performance requires the ability to understand the activity desired and normal motor strength. Failure signals cerebral dysfunction. LANGUAGE ABILITY The person with normal neurologic function can understand and communicate in spoken and written language. Does the patient answer questions appropriately? Can he or she read a sentence from a newspaper and explain its meaning? Can the patient write his or her name or copy a simple figure that the examiner has drawn? A deficiency in language function is called aphasia. Different types of aphasia result from injury to different parts of the brain (Chart 60-2). Aphasia is discussed in detail in Chapter 62. IMPACT ON LIFESTYLE The nurse assesses the impact the neurologic impairment has on the patient’s lifestyle. Issues to consider include the limitations imposed on the patient by any deficit and the patient’s role in society, including family and community roles. The plan of care that the nurse develops needs to address and support adaptation to the neurologic deficit and continued function to the extent possible within the patient’s support system. DOCUMENTATION OF FINDINGS Interpretation and documentation of neurologic abnormalities, particularly mental status abnormalities, should be specific and nonjudgmental. Lengthy descriptions and the use of terms such as “inappropriate” or “demented” should be avoided. Terms such as these often mean different things to different people and are therefore not useful when describing behavior. The examiner records and reports specific observations regarding orientation, level of consciousness, emotional state, or thought content, all of which permit comparison by others over time. Analysis and the conclusions that may be drawn from these findings usually depend on the examiner’s knowledge of neuroanatomy, neurophysiology, and neuropathology.
Examining the Cranial Nerves Table 60-5 describes how to assess the cranial nerves. Opposite sides of the face and neck are compared throughout the examination.
Examining the Motor System A thorough examination of the motor system includes an assessment of muscle size, tone, and strength, coordination, and balance. The patient is instructed to walk across the room while the examiner observes posture and gait. The muscles are inspected, and palpated if necessary, for their size and symmetry. Any evidence of atrophy or involuntary movements (tremors, tics) is noted. Muscle tone (the tension present in a muscle at rest) is evaluated by palpating various muscle groups at rest and during passive movement. Resistance to these movements is assessed and documented.
Types of Agnosia and Corresponding Sites of Lesions
Type of Agnosia Visual Auditory Tactile Body parts and relationships
Affected Cerebral Area Occipital lobe Temporal lobe (lateral and superior portions) Parietal lobe Parietal lobe (posteroinferior regions)
Chart 60-2
Types of Aphasia and Region of Brain Involved
Type of Aphasia Auditory-receptive Visual-receptive Expressive speaking Expressive writing
Brain Area Involved Temporal lobe Parietal-occipital area Inferior posterior frontal areas Posterior frontal area
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Table 60-5
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• Assessing Cranial Nerve Function
CRANIAL NERVE
CLINICAL EXAMINATION
I (olfactory) II (optic) III (oculomotor) IV (trochlear) VI (abducens) V (trigeminal)
With eyes closed, the patient identifies familiar odors (coffee, tobacco). Each nostril is tested separately. Snellen eye chart; visual fields; ophthalmoscopic examination For cranial nerves III, IV, and VI: test for ocular rotations, conjugate movements, nystagmus. Test for pupillary reflexes, and inspect eyelids for ptosis.
VII (facial)
VIII (acoustic)
IX (glossopharyngeal) X (vagus)
XI (spinal accessory)
XII (hypoglossal)
Have patient close the eyes. Touch cotton to forehead, cheeks, and jaw. Sensitivity to superficial pain is tested by using the sharp and dull ends of a broken tongue blade. Alternate between the sharp point and the dull end. Patient reports “sharp” or “dull” with each movement. If responses are incorrect, test for temperature sensation. Test tubes of cold and hot water are used alternately. While the patient looks up, lightly touch a wisp of cotton against the temporal surface of each cornea. A blink and tearing are normal responses. Have the patient clench and move the jaw from side to side. Palpate the masseter and temporal muscles, noting strength and equality. Observe for symmetry while the patient performs facial movements: smiles, whistles, elevates eyebrows, frowns, tightly closes eyelids against resistance (examiner attempts to open them). Observe face for flaccid paralysis (shallow nasolabial folds). Patient extends tongue. Ability to discriminate between sugar and salt is tested. Whisper or watch-tick test Test for lateralization (Weber) Test for air and bone conduction (Rinne) Assess patient’s ability to discriminate between sugar and salt on posterior third of the tongue. Depress a tongue blade on posterior tongue, or stimulate posterior pharynx to elicit gag reflex. Note any hoarseness in voice. Have patient say “ah.” Observe for symmetric rise of uvula and soft palate. Palpate and note strength of trapezius muscles while patient shrugs shoulders against resistance. Palpate and note strength of each sternocleidomastoid muscle as patient turns head against opposing pressure of the examiner’s hand. While the patient protrudes the tongue, any deviation or tremors are noted. The strength of the tongue is tested by having the patient move the protruded tongue from side to side against a tongue depressor.
Abnormalities in tone include spasticity (increased muscle tone), rigidity (resistance to passive stretch), and flaccidity. MUSCLE STRENGTH Assessing the patient’s ability to flex or extend the extremities against resistance tests muscle strength. The function of an individual muscle or group of muscles is evaluated by placing the muscle at a disadvantage. The quadriceps, for example, is a powerful muscle responsible for straightening the leg. Once the leg is straightened, it is exceedingly difficult for the examiner to flex the knee. Conversely, if the knee is flexed and the patient is asked to straighten the leg against resistance, a more subtle disability can be elicited. The evaluation of muscle strength compares the sides of the body to each other. For example, the right upper extremity is compared to the left upper extremity. In this way, subtle differences in muscle strength can be more easily detected and accurately described. Clinicians use a five-point scale to rate muscle strength (O’Hanlon-Nichols, 1999). A 5 indicates full power of contraction against gravity and resistance or normal muscle strength; 4 indicates fair but not full strength against gravity and a moderate amount of resistance or slight weakness; 3 indicates just sufficient strength to overcome the force of gravity or moderate weakness; 2 indicates the ability to move but not to overcome the force of gravity or severe weakness; 1 indicates minimal contractile power—weak muscle contraction can be palpated but no move-
ment is noted—or very severe weakness; and 0 indicates complete paralysis. A stick figure may be used to record muscle strength and is a precise form of documenting findings. Distal and proximal strength in both upper and lower extremities is recorded using the five-point scale (Fig. 60-14). Assessment of muscle strength can be as detailed as necessary. One may quickly test the strength of the proximal muscles of the upper and lower extremities, always comparing both sides. The strength of the finer muscles that control the function of the hand (hand grasp) and the foot (dorsiflexion and plantar flexion) can then be assessed. BALANCE AND COORDINATION Cerebellar influence on the motor system is reflected in balance control and coordination. Coordination in the hands and upper extremities is tested by having the patient perform rapid, alternating movements and point-to-point testing. First, the patient is instructed to pat his or her thigh as fast as possible with each hand separately. Then the patient is instructed to alternately pronate and supinate the hand as rapidly as possible. Lastly, the patient is asked to touch each of the fingers with the thumb in a consecutive motion. Speed, symmetry, and degree of difficulty are noted. Point-to-point testing is accomplished by having the patient touch the examiner’s extended finger and then his or her own nose. This is repeated several times. This assessment is then carried out with the patient’s eyes closed.
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2
4 1 5
1
2
5
5
FIGURE 60-14 A stick figure may be used to record muscle strength as follows: 5, full range of motion against gravity and resistance; 4, full range of motion against gravity and a moderate amount of resistance; 3, full range of motion against gravity only; 2, full range of motion when gravity is eliminated; 1, a weak muscle contraction when muscle is palpated, but no movement; and 0, complete paralysis. Coordination in the lower extremities is tested by having the patient run the heel down the anterior surface of the tibia of the other leg. Each leg is tested in turn. Ataxia is defined as incoordination of voluntary muscle action, particularly of the muscle groups used in activities such as walking or reaching for objects. The presence of ataxia or tremors (rhythmic, involuntary movements) during these movements suggests cerebellar disease. It is not necessary to carry out each of these assessments for coordination. During a routine examination, it is advisable to perform a simple screening of the upper and lower extremities by having the patient perform either rapid, alternating movements or point-to-point testing. When abnormalities are observed, a more thorough examination is indicated. The Romberg test is a screening test for balance. The patient stands with feet together and arms at the side, first with eyes open and then with both eyes closed for 20 to 30 seconds. The examiner stands close to reassure the patient of support if he or she begins to fall. Slight swaying is normal, but a loss of balance is abnormal and is considered a positive Romberg test. Additional cerebellar tests for balance in the ambulatory patient include hopping in place, alternating knee bends, and heel-to-toe walking (both forward and backward).
Examining the Reflexes The motor reflexes are involuntary contractions of muscles or muscle groups in response to abrupt stretching near the site of the muscle’s insertion. The tendon is struck directly with a reflex hammer or indirectly by striking the examiner’s thumb, which is placed firmly against the tendon. Testing these reflexes enables the examiner to assess involuntary reflex arcs that depend on the presence of afferent stretch receptors, spinal synapses, efferent motor fibers, and a variety of modifying influences from higher levels. Common reflexes that may be tested include the deep tendon reflexes (biceps, brachioradialis, triceps, patellar, and ankle reflexes) and superficial or cutaneous reflexes (abdominal reflexes and plantar or Babinski response) (Fig. 60-15).
TECHNIQUE A reflex hammer is used to elicit a deep tendon reflex. The handle of the hammer is held loosely between the thumb and index finger, allowing a full swinging motion. The wrist motion is similar to that used during percussion. The extremity is positioned so that the tendon is slightly stretched. This requires a sound knowledge of the location of muscles and their tendon attachments. The tendon is then struck briskly, and the response is compared with that on the opposite side of the body. A wide variation in reflex response may be considered normal; it is more important, however, that the reflexes be symmetrically equivalent. When the comparison is made, both sides should be equivalently relaxed and each tendon struck with equal force. Valid findings depend on several factors: proper use of the reflex hammer, proper positioning of the extremity, and a relaxed patient. If the reflexes are symmetrically diminished or absent, the examiner may use reinforcement to increase reflex activity. This involves the isometric contraction of other muscle groups. If lower extremity reflexes are diminished or absent, the patient is instructed to lock the fingers together and pull in opposite directions. Having the patient clench the jaw or press the heels against the floor or examining table may similarly elicit more reliable biceps, triceps, and brachioradialis reflexes. GRADING THE REFLEXES The absence of reflexes is significant, although ankle jerks (Achilles reflex) may be normally absent in older people. Deep tendon reflex responses are often graded on a scale of 0 to 4+. A 4+ indicates a hyperactive reflex, often indicating pathology; 3+ indicates a response that is more brisk than average but may be normal or indicative of disease; 2+ indicates an average or normal response; 1+ indicates a hypoactive or diminished response; and 0 indicates no response. As stated previously, scale ratings are highly subjective. Findings can be recorded as a fraction, indicating the scale range (eg, 2/4). Some examiners prefer to use the terms present, absent, and diminished when describing reflexes. As with muscle strength recording, a stick figure such as the one shown in Chart 60-3 may also be used to record numerical findings. BICEPS REFLEX The biceps reflex is elicited by striking the biceps tendon of the flexed elbow. The examiner supports the forearm with one arm while placing the thumb against the tendon and striking the thumb with the reflex hammer. The normal response is flexion at the elbow and contraction of the biceps (see Fig. 60-15A). TRICEPS REFLEX To elicit a triceps reflex, the patient’s arm is flexed at the elbow and positioned in front of the chest. The examiner supports the patient’s arm and identifies the triceps tendon by palpating 2.5 to 5 cm (1 to 2 in) above the elbow. A direct blow on the tendon normally produces contraction of the triceps muscle and extension of the elbow (see Fig. 60-15B). BRACHIORADIALIS REFLEX With the patient’s forearm resting on the lap or across the abdomen, the brachioradialis reflex is assessed. A gentle strike of the hammer 2.5 to 5 cm (1 to 2 in) above the wrist results in flexion and supination of the forearm. PATELLAR REFLEX The patellar reflex is elicited by striking the patellar tendon just below the patella. The patient may be in a sitting or a lying posi-
Chapter 60
A
B
D
E
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C
FIGURE 60-15
Techniques for eliciting major reflexes. (A) Biceps reflex. (B) Triceps reflex. (C) Patellar reflex. (D) Ankle or Achilles reflex. (E) Babinski response. From Weber, J. & Kelley, J. (2003). Health assessment in nursing (2nd ed.). Philadelphia: Lippincott Williams & Wilkins. © B. Proud.
tion. If the patient is supine, the examiner supports the legs to facilitate relaxation of the muscles. Contractions of the quadriceps and knee extension are normal responses (see Fig. 60-15C ). ANKLE REFLEX To elicit an ankle (Achilles) reflex, the foot is dorsiflexed at the ankle and the hammer strikes the stretched Achilles tendon (see Fig. 60-15D). This reflex normally produces plantar flexion. If the examiner cannot elicit the ankle reflex and suspects that the patient cannot relax, the patient is instructed to kneel on a chair or similar elevated, flat surface. This position places the ankles in dorsiflexion and reduces any muscle tension in the gastrocnemius. The Achilles tendons are struck in turn, and plantar flexion is usually demonstrated.
CLONUS When reflexes are very hyperactive, a phenomenon called clonus may be elicited. If the foot is abruptly dorsiflexed, it may continue to “beat” two or three times before it settles into a position of rest. Occasionally with central nervous system disease this activity persists and the foot does not come to rest while the tendon is being stretched but persists in repetitive activity. The unsustained clonus associated with normal but hyperactive reflexes is not considered pathologic. Sustained clonus always indicates the presence of central nervous system disease and requires further evaluation. SUPERFICIAL REFLEXES The major superficial reflexes include corneal, gag or swallowing, upper/lower abdominal, cremasteric (men only), plantar, and
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Chart 60-3
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Documenting Reflexes
Deep tendon reflexes are graded on a scale of 0 to 4: 0 1+ 2+ 3+ 4+
No response Diminished (hypoactive) Normal Increased (may be interpreted as normal) Hyperactive (hyperreflexia)
The deep tendon responses and plantar reflexes are commonly recorded on stick figures. The arrow points downward if the plantar response is normal and upward if the response is abnormal.
++
++
++
++
++ + +
BABINSKI RESPONSE A well-known reflex indicative of central nervous system disease affecting the corticospinal tract is the Babinski reflex. In someone with an intact central nervous system, if the lateral aspect of the sole of the foot is stroked, the toes contract and are drawn together (see Fig. 60-15E ). In patients who have central nervous system disease of the motor system, however, the toes fan out and are drawn back. This is normal in newborns but represents a serious abnormality in adults. Several other reflexes convey similar information. Many of them are interesting but not particularly informative.
Sensory Examination The sensory system is even more complex than the motor system because sensory modalities are carried in different tracts located in different portions of the spinal cord. The sensory examination is largely subjective and requires the cooperation of the patient. The examiner should be familiar with dermatomes that represent the distribution of the peripheral nerves that arise from the spinal
+ +
++
++
+
perianal. These reflexes are graded differently than the motor reflexes and are noted to be present (+) or absent (-). Of these, only three are tested commonly. The corneal reflex is tested carefully using a clean wisp of cotton and lightly touching the outer corner of each eye on the sclera. The reflex is present if the action elicits a blink. Conditions such as a cerebrovascular accident or coma might result in loss of this reflex, either unilaterally or bilaterally. Loss of this reflex indicates the need for eye protection and possible lubrication to prevent corneal damage. The gag reflex is elicited by gently touching the posterior pharynx with a cotton-tipped applicator; first on one side of the uvula and then the other. Positive response is an equal elevation of the uvula and “gag” with stimulation. Absent response on one or both sides can be seen following a cerebrovascular accident and requires careful evaluation and treatment of the resultant swallowing dysfunction to prevent aspiration of food and fluids into the lungs. The plantar reflex is elicited by stroking the lateral side of the foot with a tongue blade or the handle of a reflex hammer. Stimulation normally causes toe flexion. Toe fanning (positive Babinski) is an abnormal response and is discussed below (O’Hanlon-Nichols, 1999).
++
+
cord (see Fig. 60-11). Most sensory deficits result from peripheral neuropathy and follow anatomic dermatomes. Exceptions to this include major destructive lesions of the brain; loss of sensation, which may affect an entire side of the body; and the neuropathies associated with alcoholism, which occur in a gloveand-stocking distribution or over the entire hand or foot in areas traditionally covered by a glove or sock. Assessment of the sensory system involves tests for tactile sensation, superficial pain, vibration, and position sense (proprioception). During the sensory assessment, the patient’s eyes are closed. Simple directions and reassurance that the examiner will not hurt or startle the patient encourage the cooperation of the patient. Tactile sensation is assessed by lightly touching a cotton wisp to corresponding areas on each side of the body. The sensitivity of proximal parts of the extremities is compared with that of distal parts. Pain and temperature sensations are transmitted together in the lateral part of the spinal cord, so it is unnecessary to test for temperature sense in most circumstances. Determining the patient’s sensitivity to a sharp object can assess superficial pain perception. The patient is asked to differentiate between the sharp and dull ends of a broken wooden cotton swab or tongue blade; using a safety pin is inadvisable because it breaks the integrity of the skin. Both the sharp and dull sides of the object are applied with equal intensity at all times, and as with the motor evaluation the two sides are compared. Vibration and proprioception are transmitted together in the posterior part of the cord. Vibration may be evaluated through the use of a low-frequency (128- or 256-Hz) tuning fork. The handle of the vibrating fork is placed against a bony prominence, and the patient is asked whether he or she feels a sensation and is instructed to signal the examiner when the sensation ceases. Common locations used to test for vibratory sense include the distal joint of the great toe and the proximal thumb joint. If the patient does not perceive the vibrations at the distal bony prominences, the examiner progresses upward with the tuning fork until the patient perceives the vibrations. As with all measurements of sensation, a side-to-side comparison is made. Position sense or proprioception may be determined by asking the patient to close both eyes and indicate, as the great toe is alternately moved up and down, in which direction movement has taken place. Vibration and position sense are often lost
Chapter 60 together, frequently in circumstances in which all others remain intact. Integration of sensation in the brain is evaluated next. This may be performed by testing two-point discrimination—when the patient is touched with two sharp objects simultaneously, are they perceived as two or as one? If touched simultaneously on opposite sides of the body, the patient should normally report being touched in two places. If only one site is reported, the one not being recognized is said to demonstrate extinction. Another test of higher cortical sensory ability is stereognosis. The patient is instructed to close both eyes and identify a variety of objects (eg, keys, coins) that are placed in one hand by the examiner. Gerontologic Considerations The nervous system undergoes many changes during the normal aging process and is extremely vulnerable to general systemic illness. Changes throughout the nervous system vary in degree as the person ages. Nerve fibers that connect directly to muscles show little decline in function with age, as do simple neurologic functions that involve a number of connections in the spinal cord. Disease in the elderly often makes it difficult to distinguish normal from abnormal changes. However, it is important for clinicians not to attribute abnormality or dysfunction to aging without appropriate investigation (Kaye & Quinn, 2000). Structural Changes. There are a number of alterations that occur with increasing age. Brain weight decreases, as does the number of synapses. A loss of neurons occurs in select regions of the brain. There is a reduction in cerebral blood flow and metabolism. Temperature regulation becomes less efficient. In the peripheral nervous system, myelin is lost, resulting in a decrease in conduction velocity in some nerves. There is an overall reduction in muscle bulk and the electrical activity within muscles. Taste buds atrophy and nerve cell fibers in the olfactory bulb degenerate. Nerve cells in the vestibular system of the inner ear, cerebellum, and proprioceptive pathways also degenerate. Deep tendon reflexes can be decreased or in some cases absent. Hypothalamic function is modified such that stage IV sleep is reduced. There is an overall slowing of autonomic nervous system responses. Pupillary responses are reduced or may not appear at all in the presence of cataracts (Kaye & Quinn, 2000). Motor Alterations. There is an overall reduction in muscle bulk, with atrophy most easily noted in the hands (Kaye & Quinn, 2000). Changes in motor function often result in a flexed posture, shuffling gait, and rigidity of movement. These changes can create difficulties for the older person in maintaining or recovering balance. Strength and agility are diminished, and reaction time and movement time are decreased. Repetitive movements and mild tremors may be noted during an examination and may be of concern to the individual. Observation of gait may reveal a wide-based gait with balance difficulties. Sensory Alterations. Sensory isolation due to visual and hearing loss can cause confusion, anxiety, disorientation, misinterpretation of the environment, and feelings of inadequacy. Sensory alterations may require modification of the home environment, such as large-print reading materials or sound enhancement for the telephone, as well as extra orientation to new surroundings. Simple explanations of routines, the location of the bathroom, and how to operate the call bell are just a few examples of information the elderly patient needs when hospitalized.
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Temperature Regulation and Pain Perception. Other manifestations of neurologic changes are related to temperature regulation and pain. The elderly patient may feel cold more readily than heat and may require extra covering when in bed; a room temperature somewhat higher than usual may be desirable. Reaction to painful stimuli may be decreased with age. Because pain is an important warning signal, caution must be used when hot or cold packs are used. The older patient may be burned or suffer frostbite before being aware of any discomfort. Complaints of pain, such as abdominal discomfort or chest pain, may be more serious than the patient’s perception might indicate and thus require careful evaluation. Taste and Smell Alterations. The acuity of the taste buds decreases with age; along with an altered olfactory sense, this may cause a decreased appetite and subsequent weight loss. Extra seasoning often increases food intake as long as it does not cause gastric irritation. A decreased sense of smell due to atrophy of olfactory organs may present a safety hazard, because elderly people living alone may be unable to detect household gas leaks or fires. Smoke and carbon monoxide detectors, important for all, are critical for the elderly. Tactile and Visual Alterations. Another neurologic alteration in the elderly patient is the dulling of tactile sensation due to a decrease in the number of areas of the body responding to all stimuli and in the number and sensitivity of sensory receptors. There may be difficulty in identifying objects by touch, and because fewer tactile cues are received from the bottom of the feet, the person may get confused as to body position and location. These factors, combined with sensitivity to glare, decreased peripheral vision, and a constricted visual field, may result in disorientation, especially at night when there is little or no light in the room. Because the elderly person takes longer to recover visual sensitivity when moving from a light to dark area, night-lights and a safe and familiar arrangement of furniture are essential. Mental Status. Mental status is evaluated while the history is obtained, and areas of judgment, intelligence, memory, affect, mood, orientation, speech, and grooming are assessed. Family members who bring the patient to the attention of the health care provider may have noticed changes in the patient’s mental status. Drug toxicity should always be suspected as a causative factor when the patient has a change in mental status. Delirium (mental confusion, usually with delusions and hallucinations) is seen in elderly patients who have underlying central nervous system damage or are experiencing an acute condition such as infection, adverse medication reaction, or dehydration. About 25% of patients over the age of 70 admitted to the hospital have delirium ( Johnson, 2001). The cause is often reversible and treatable (as in drug toxicity, vitamin B deficiency, or thyroid disease). Depression may produce impairment of attention and memory. For elderly patients, delirium, which is an acute change in mental status attributable to a treatable medical problem, must be differentiated from dementia, which is a chronic and irreversible deterioration of cognitive status. Nursing Implications. Nursing care for patients with age-related changes to the nervous system and for patients with long-term neurologic disability who are aging should include the modifications previously described. In addition, the consequences of any neurologic deficit and its impact on overall function such as activities of daily living, use of assistive devices, and individual
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coping need to be assessed and considered in planning care for patients. Patient teaching is also affected because the nurse must understand the altered responses and the changing needs of the elderly patient before beginning to teach. When caring for the elderly patient, the nurse adapts activities such as preoperative teaching, diet therapy, and instruction about new medications, their timing, and doses to the patient’s needs and capabilities. The nurse considers the presence of decline in fine motor movement and failing vision. When using visual materials for teaching or menu selection, adequate lighting without glare, contrasting colors, and large print are used to offset visual difficulties caused by rigidity and opacity of the lens in the eye and slower pupillary reaction. Procedures and preparations needed for diagnostic tests are explained, taking into account the possibility of impaired hearing and slowed responses in the elderly. Even with hearing loss, the elderly patient often hears adequately if the speaker uses a lowpitched, clear voice; shouting only makes it harder for the patient to understand the speaker. Providing auditory and visual cues aids understanding; if the patient has a significant hearing or visual loss, assistive devices, a signer, or a translator may be needed. Teaching at an unrushed pace and using reinforcement enhance learning and retention. Material should be short, concise, and concrete. Vocabulary is matched to the patient’s ability, and terms are clearly defined. The elderly patient requires adequate time to receive and respond to stimuli, to learn, and to react. These measures allow comprehension, memory, and formation of association and concepts.
Diagnostic Evaluation COMPUTED TOMOGRAPHY SCANNING Computed tomography (CT) makes use of a narrow x-ray beam to scan the head in successive layers. The images provide crosssectional views of the brain, with distinguishing differences in tissue densities of the skull, cortex, subcortical structures, and ventricles. The brightness of each slice of the brain in the final image is proportional to the degree to which it absorbs x-rays. The image is displayed on an oscilloscope or TV monitor and is photographed and stored digitally (Hinkle, 1999a). Lesions in the brain are seen as variations in tissue density differing from the surrounding normal brain tissue. Abnormalities of tissue indicate possible tumor masses, brain infarction, displacement of the ventricles, and cortical atrophy. Whole-body CT scanners allow sections of the spinal cord to be visualized. The injection of a water-soluble iodinated contrast agent into the subarachnoid space through lumbar puncture improves the visualization of the spinal and intracranial contents on these images. The CT scan, along with magnetic resonance imaging (MRI), has largely replaced myelography as a diagnostic procedure for the diagnosis of herniated lumbar disks. CT scanning is usually performed first without contrast material and then with intravenous contrast enhancement. The patient lies on an adjustable table with the head held in a fixed position, while the scanning system rotates around the head and produces cross-sectional images. The patient must lie with the head held perfectly still without talking or moving the face, because head motion will distort the image. CT scanning is noninvasive and painless and has a high degree of sensitivity for detecting lesions. With advances in CT scan-
ning, the number of disorders and injuries that can be diagnosed is increasing.
Nursing Interventions Essential nursing interventions include preparation for the procedure and patient monitoring. Preparation includes teaching the patient about the need to lie quietly throughout the procedure. A review of relaxation techniques may be helpful for claustrophobic patients. Sedation can be used if agitation, restlessness, or confusion will interfere with a successful study (Hinkle, 1999a). Ongoing patient monitoring during sedation is necessary. If a contrast agent is used, the patient must be assessed before the CT scan for an iodine/shellfish allergy, as the contrast agent is iodine-based. An intravenous line for injection of the contrast agent and a period of fasting (usually 4 hours) are required prior to the study. Patients who receive an intravenous or inhalation contrast agent are monitored during and after the procedure for allergic reactions and other side effects, including flushing, nausea, and vomiting.
POSITRON EMISSION TOMOGRAPHY Positron emission tomography (PET) is a computer-based nuclear imaging technique that produces images of actual organ functioning. The patient either inhales a radioactive gas or is injected with a radioactive substance that emits positively charged particles. When these positrons combine with negatively charged electrons (normally found in the body’s cells), the resultant gamma rays can be detected by a scanning device that produces a series of two-dimensional views at various levels of the brain. This information is integrated by a computer and gives a composite picture of the brain at work. PET permits the measurement of blood flow, tissue composition, and brain metabolism and thus indirectly evaluates brain function. The brain is one of the most metabolically active organs, consuming 80% of the glucose the body uses. PET measures this activity in specific areas of the brain and can detect changes in glucose use. This test is useful in showing metabolic changes in the brain (Alzheimer’s disease), locating lesions (brain tumor, epileptogenic lesions), identifying blood flow and oxygen metabolism in patients with strokes, evaluating new therapies for brain tumors, and revealing biochemical abnormalities associated with mental illness. The isotopes used have a very short half-life and are expensive to produce, requiring specialized equipment for production. PET scanning has been useful in research settings for the last 20 years and is now becoming more available in clinical settings. Improvements in scanning itself and the production of isotopes, as well as the advent of reimbursement by third-party payers, has increased the availability of PET studies (Gjedde et al., 2001).
Nursing Interventions Key nursing interventions include patient preparation, which involves explaining the test and teaching the patient about inhalation techniques and the sensations (eg, dizziness, lightheadedness, and headache) that may occur. The intravenous injection of the radioactive substance produces similar side effects. Relaxation exercises may reduce anxiety during the test.
Chapter 60 SINGLE PHOTON EMISSION COMPUTED TOMOGRAPHY
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Single photon emission computed tomography (SPECT) is a three-dimensional imaging technique that uses radionuclides and instruments to detect single photons. It is a perfusion study that captures a moment of cerebral blood flow at the time of injection of a radionuclide (Huntington, 1999). Gamma photons are emitted from a radiopharmaceutical agent administered to the patient and are detected by a rotating gamma camera or cameras; the image is sent to a minicomputer. This approach allows areas behind overlying structures or background to be viewed, greatly increasing the contrast between normal and abnormal tissue. It is relatively inexpensive, and the duration is similar to that of a CT scan. SPECT is useful in detecting the extent and location of abnormally perfused areas of the brain, thus allowing detection, localization, and sizing of stroke (before it is visible by CT scan), localization of seizure foci in epilepsy, and evaluation of perfusion before and after neurosurgical procedures. Pregnancy and breastfeeding are contraindications to SPECT.
magnets in a magnetic field. In combination with radiofrequency pulses, the protons emit signals, which are converted to images. MRI has the potential for identifying a cerebral abnormality earlier and more clearly than other diagnostic tests. It can provide information about the chemical changes within cells, allowing the clinician to monitor a tumor’s response to treatment. It is particularly useful in the diagnosis of multiple sclerosis and can describe the activity and extent of disease in the brain and spinal cord. MRI does not involve ionizing radiation. Several newer MRI techniques, including magnetic resonance angiography (MRA), diffusion-weighted imaging (DWI), perfusion-weighted imaging (PWI), and fluid attenuation inversion recovery (FLAIR), are becoming more widely used (Hinkle, 1999b; Shellock, 2001). The use of MRA allows visualization of the cerebral vasculature without the administration of an arterial contrast agent. A substantial amount of research on the techniques of DWI, PWI, and FLAIR shows promise for clearer visualization and the early diagnosis of ischemic stroke (Hinkle, 1999b). At present MRI is most valuable in the diagnosis of nonacute conditions, as the test takes up to an hour to complete.
Nursing Interventions
Nursing Interventions
The nursing interventions for SPECT primarily include patient preparation and patient monitoring. Teaching about what to expect before the test can allay anxiety and ensure patient cooperation during the test. Premenopausal women are advised to practice effective contraception before and for several days after testing, and the woman who is breastfeeding is instructed to stop nursing for the period of time recommended by the nuclear medicine department. The nurse may need to accompany and monitor the patient during transport to the nuclear medicine department for the scan. Patients are monitored during and after the procedure for allergic reactions to the radiopharmaceutical agent. In a few institutions nurses with special education and training inject the contrast agent before a SPECT scan (Fischbach, 2002; Huntington, 1999).
Patient preparation should include teaching relaxation techniques and informing the patient that he or she will be able to talk to the staff by means of a microphone located inside the scanner. Many MRI suites provide headphones so patients can listen to the music of their choice during the procedure. Before the patient enters the room where the MRI is to be performed, all metal objects and credit cards (the magnetic field can erase them) are removed. No metal objects may be brought into the room where the MRI is located (Shellock, 2001): this includes oxygen tanks, traditional ventilators, or even stethoscopes. The magnetic field generated by the unit is so strong that any metal-containing items will be strongly attracted and literally can be pulled away with such force that they fly like projectiles toward the magnet. There is a risk of severe injury and death; furthermore, damage to a very expensive piece of equipment may occur. A patient history is obtained to determine the presence of any metal objects (eg, aneurysm clips, orthopedic hardware, pacemakers, artificial heart valves, intrauterine devices). These objects could malfunction, be dislodged, or heat up as they absorb energy. Cochlear implants will be inactivated by MRI; therefore, other imaging procedures are considered.
MAGNETIC RESONANCE IMAGING Magnetic resonance imaging (MRI) uses a powerful magnetic field to obtain images of different areas of the body (Fig. 60-16). This diagnostic test involves altering hydrogen ions in the body. Placing the patient into a powerful magnetic field causes the hydrogen nuclei (protons) within the body to align like small
!
FIGURE 60-16
Technician explains what to expect during an MRI.
NURSING ALERT For patient safety, the nurse must make sure no patient care equipment (eg, portable oxygen tanks) that contains metal or metal parts enters the room where the MRI is located.
The patient lies on a flat platform that is moved into a tube housing the magnet. The scanning process is painless, but the patient hears loud thumping of the magnetic coils as the magnetic field is being pulsed. Because the MRI scanner is a narrow tube, patients may experience claustrophobia; sedation may be prescribed in these circumstances. Newer versions of MRI machines are less claustrophobic than the earlier devices and are available in some locations. However, the images produced on these machines are not optimal, and the traditional device is preferable for accurate diagnosis.
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CEREBRAL ANGIOGRAPHY Cerebral angiography is an x-ray study of the cerebral circulation with a contrast agent injected into a selected artery. Cerebral angiography is a valuable tool to investigate vascular disease, aneurysms, and arteriovenous malformations. It is frequently performed before craniotomy to assess the patency and adequacy of the cerebral circulation and to determine the site, size, and nature of the pathologic processes (Fischbach, 2002; Frizzell, 1998). Most cerebral angiograms are performed by threading a catheter through the femoral artery in the groin and up to the desired vessel. Alternatively, direct puncture of the carotid or vertebral artery or retrograde injection of a contrast agent into the brachial artery may be performed. In digital subtraction angiography (DSA), x-ray images of the area in question are obtained before and after the injection of a contrast agent. The computer analyzes the differences between the two images and produces an enhanced image of the carotid and vertebral arterial systems. The injection for a DSA can be given through a peripheral vein (Fischbach, 2002; Rowland, 2000).
Nursing Interventions The patient should be well hydrated, and clear liquids are usually permitted up to the time of a regular arteriogram or DSA. Before going to the x-ray department, the patient is instructed to void. The locations of the appropriate peripheral pulses are marked with a felt-tip pen. The patient is instructed to remain immobile during the angiogram process and is told to expect a brief feeling of warmth in the face, behind the eyes, or in the jaw, teeth, tongue, and lips, and a metallic taste when the contrast agent is injected. After the groin is shaved and prepared, a local anesthetic is administered to prevent pain at the insertion site and to reduce arterial spasm. A catheter is introduced into the femoral artery, flushed with heparinized saline, and filled with contrast agent. Fluoroscopy is used to guide the catheter to the appropriate vessels. During injection of the contrast agent, images are made of the arterial and venous phases of circulation through the brain. Nursing care after cerebral angiography includes observation for signs and symptoms of altered cerebral blood flow. In some instances, patients may experience major or minor arterial blockage due to embolism, thrombosis, or hemorrhage, producing a neurologic deficit. Signs of such an occurrence include alterations in the level of responsiveness and consciousness, weakness on one side of the body, motor or sensory deficits, and speech disturbances. Therefore, it is necessary to observe the patient frequently for these signs and to report them immediately if they occur. The injection site is observed for hematoma formation (a localized collection of blood), and an ice bag may be applied intermittently to the puncture site to relieve swelling and discomfort. Because a hematoma at the puncture site or embolization to a distant artery affects the peripheral pulses, these pulses are monitored frequently. The color and temperature of the involved extremity are assessed to detect possible embolism.
MYELOGRAPHY A myelogram is an x-ray of the spinal subarachnoid space taken after the injection of a contrast agent into the spinal subarachnoid space through a lumbar puncture. It outlines the spinal subarachnoid space and shows any distortion of the spinal cord or spinal dural sac caused by tumors, cysts, herniated vertebral disks,
or other lesions. Water-based agents have replaced oil-based agents and their use has reduced side effects and complications; these agents disperse upward through the CSF. Myelography is performed less frequently today because of the sensitivity of CT scanning and MRI (Hickey, 2003).
Nursing Interventions Because many patients have misconceptions about this procedure, the nurse clarifies the explanation given by the physician and answers questions. The patient is informed about what to expect during the procedure and should be aware that changes in position may be made during the procedure. The meal that normally would be eaten before the procedure is omitted. A sedative may be prescribed to help the patient cope with this rather lengthy test. Patient preparation for lumbar puncture is discussed later in this chapter. After myelography, the patient lies in bed with the head of the bed elevated 30 to 45 degrees. The patient is advised to remain in bed in the recommended position for 3 hours or as prescribed by the physician. The patient is encouraged to drink liberal amounts of fluid for rehydration and replacement of CSF and to decrease the incidence of postlumbar puncture headache. The blood pressure, pulse, respiratory rate, and temperature are monitored, as well as the patient’s ability to void. Untoward signs include headache, fever, stiff neck, photophobia (sensitivity to light), seizures, and signs of chemical or bacterial meningitis.
NONINVASIVE CAROTID FLOW STUDIES Noninvasive carotid flow studies use ultrasound imagery and Doppler measurements of arterial blood flow to evaluate carotid and deep orbital circulation. The graph produced indicates blood velocity. Increased blood velocity can indicate stenosis or partial obstruction. These tests are often obtained before arteriography, which carries a higher risk of stroke or death (Fischbach, 2002; Hickey, 2003). Carotid Doppler, carotid ultrasonography, oculoplethysmography, and ophthalmodynamometry are four common noninvasive vascular techniques that permit evaluation of arterial blood flow and detection of arterial stenosis, occlusion, and plaques.
TRANSCRANIAL DOPPLER Transcranial Doppler uses the same noninvasive techniques as carotid flow studies except that it records the blood flow velocities of the intracranial vessels. Flow velocities of the basal artery can be measured through thin areas of the temporal and occipital bones of the skull. A hand-held Doppler probe emits a pulsed beam; the signal is reflected by the moving red blood cells within the blood vessels (Falyar, 1999). Transcranial Doppler sonography is a noninvasive technique that is helpful in assessing vasospasm (a complication following subarachnoid hemorrhage), altered cerebral blood flow found in occlusive vascular disease or stroke, and other cerebral pathology.
Nursing Interventions When a carotid flow study or transcranial Doppler is scheduled, the procedure is described to the patient. The patient is informed that this is a noninvasive test, that a hand-held transducer will be placed over the neck and orbits of the eyes, and that some type of water-soluble jelly is used on the transducer. Either one of these low-risk tests can be performed at the patient’s bedside.
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ELECTROENCEPHALOGRAPHY
EVOKED POTENTIAL STUDIES
An electroencephalogram (EEG) represents a record of the electrical activity generated in the brain. It is obtained through electrodes applied on the scalp or through microelectrodes placed within the brain tissue. It provides a physiologic assessment of cerebral activity. The EEG is a useful test for diagnosing and evaluating seizure disorders, coma, or organic brain syndrome. Tumors, brain abscesses, blood clots, and infection may cause abnormal patterns in electrical activity. The EEG is also used in making a determination of brain death. Electrodes are applied to the scalp to record the electrical activity in various regions of the brain. The amplified activity of the neurons between any two of these electrodes is recorded on continuously moving paper; this record is called the encephalogram. For a baseline recording, the patient lies quietly with both eyes closed. The patient may be asked to hyperventilate for 3 to 4 minutes and then look at a bright, flashing light for photic stimulation. These activation procedures are performed to evoke abnormal electrical discharges, such as seizure potentials. A sleep EEG may be recorded after sedation because some abnormal brain waves are seen only when the patient is asleep. If the epileptogenic area is inaccessible to conventional scalp electrodes, nasopharyngeal electrodes may be used. Depth recording of EEG is performed by introducing electrodes stereotactically (radiologically placed using instrumentation) into a target area of the brain, as indicated by the patient’s seizure pattern and scalp EEG. It is used to identify patients who may benefit from surgical excision of epileptogenic foci. Special transsphenoidal, mandibular, and nasopharyngeal electrodes can be used, and video recording combined with EEG monitoring and telemetry is used in hospital settings to capture epileptiform abnormalities and their sequelae. Some epilepsy centers provide long-term ambulatory EEG monitoring with portable recording devices.
In evoked potential studies, electrodes are applied to the scalp and an external stimulus is applied to peripheral sensory receptors to elicit changes in the brain waves. Evoked changes are detected with the aid of computerized devices that extract the signal, display it on an oscilloscope, and store the data on magnetic tape or disk. These studies are based on the concept that any insult or dysfunction that can alter neuronal metabolism or disturb membrane function may change evoked responses in brain waves. In neurologic diagnosis, they reflect conduction times in the peripheral nervous system. In clinical practice, the visual, auditory, and somatosensory systems are most often tested. In visual evoked responses, the patient looks at a visual stimulus (flashing lights, a checkerboard pattern on a screen). The average of several hundred stimuli is recorded by EEG leads placed over the occiput. The transit time from the retina to the occipital area is measured using computer-averaging methods. Auditory evoked responses or brain stem evoked responses are measured by applying an auditory stimulus (a repetitive auditory click) and measuring the transit time up the brain stem into the cortex. Specific lesions in the auditory pathway modify or delay the response. In somatosensory evoked responses, the peripheral nerves are stimulated (electrical stimulation through skin electrodes) and the transit time up the spinal cord to the cortex is measured and recorded from scalp electrodes. This test is used to detect a deficit in spinal cord conduction and to monitor spinal cord function during operative procedures. Because myelinated fibers conduct impulses at a higher rate of speed, nerves with an intact myelin sheath record the highest velocity. Demyelination of nerve fibers leads to a decrease in speed of conduction, as found in Guillain-Barré syndrome, multiple sclerosis, and polyneuropathies.
Nursing Interventions To increase the chances of recording seizure activity, it is sometimes recommended that the patient be deprived of sleep on the night before the EEG. Antiseizure agents, tranquilizers, stimulants, and depressants should be withheld 24 to 48 hours before an EEG because these medications can alter the EEG wave patterns or mask the abnormal wave patterns of seizure disorders (Hickey, 2003). Coffee, tea, chocolate, and cola drinks are omitted in the meal before the test because of their stimulating effect. The meal is not omitted, however, because an altered blood glucose level can also cause changes in the brain wave patterns. The patient is informed that the standard EEG takes 45 to 60 minutes, 12 hours for a sleep EEG. The patient is assured that the procedure does not cause an electric shock and that the EEG is a diagnostic test, not a form of treatment. An EEG requires patient cooperation and ability to lie quietly during the test. Sedation is not advisable as it may lower the seizure threshold in patients with a seizure disorder and alter brain wave activity in all patients. Patients with seizures do not stop taking their antiseizure medication prior to testing. Routine EEGs use a water-soluble lubricant for electrode contact, which at the conclusion of the study can be wiped off and removed by shampooing. Sleep EEGs involve the use of collodion glue for electrode contact, which requires acetone for removal.
Nursing Interventions There is no specific patient preparation other than to explain the procedure and to reassure the patient and encourage him or her to relax. The patient is advised to remain perfectly still throughout the recording to prevent artifacts (signals not generated by the brain) that interfere with the recording and interpretation of the test.
ELECTROMYOGRAPHY An electromyogram (EMG) is obtained by introducing needle electrodes into the skeletal muscles to measure changes in the electrical potential of the muscles and the nerves leading to them. The electrical potentials are shown on an oscilloscope and amplified by a loudspeaker so that both the sound and appearance of the waves can be analyzed and compared simultaneously. An EMG is useful in determining the presence of a neuromuscular disorder and myopathies. They help to distinguish weakness due to neuropathy (functional or pathologic changes in the peripheral nervous system) from weakness due to other causes.
Nursing Interventions The procedure is explained and the patient is warned to expect a sensation similar to that of an intramuscular injection as the needle is inserted into the muscle. The muscles examined may ache for a short time after the procedure.
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NERVE CONDUCTION STUDIES Nerve conduction studies are performed by stimulating a peripheral nerve at several points along its course and recording the muscle action potential or the sensory action potential that results. Surface or needle electrodes are placed on the skin over the nerve to stimulate the nerve fibers. This test is useful in the study of peripheral neuropathies.
LUMBAR PUNCTURE AND EXAMINATION OF CEREBROSPINAL FLUID A lumbar puncture (spinal tap) is carried out by inserting a needle into the lumbar subarachnoid space to withdraw CSF. The test may be performed to obtain CSF for examination, to measure and reduce CSF pressure, to determine the presence or absence of blood in the CSF, to detect spinal subarachnoid block, and to administer antibiotics intrathecally (into the spinal canal) in certain cases of infection. The needle is usually inserted into the subarachnoid space between the third and fourth or fourth and fifth lumbar vertebrae. Because the spinal cord divides into a sheaf of nerves at the first lumbar vertebra, insertion of the needle below the level of the third lumbar vertebra prevents puncture of the spinal cord. A successful lumbar puncture requires that the patient be relaxed; an anxious patient is tense, and this may increase the pressure reading. CSF pressure with the patient in a lateral recumbent position is normally 70 to 200 mm H2O. Pressures of more than 200 mm H2O are considered abnormal. A lumbar puncture may be risky in the presence of an intracranial mass lesion because intracranial pressure is decreased by the removal of CSF, and the brain may herniate downward through the tentorium and the foramen magnum.
Queckenstedt’s Test A lumbar manometric test (Queckenstedt’s test) may be performed by compressing the jugular veins on each side of the neck during the lumbar puncture. The increase in pressure caused by the compression is noted; then the pressure is released and pressure readings are made at 10-second intervals. Normally, CSF pressure rises rapidly in response to compression of the jugular veins and returns quickly to normal when the compression is released. A slow rise and fall in pressure indicates a partial block due to a lesion compressing the spinal subarachnoid pathways. If there is no pressure change, a complete block is indicated. This test is not performed if an intracranial lesion is suspected. See Chart 60-4 for nursing guidelines for assisting with a lumbar puncture.
Cerebrospinal Fluid Analysis The CSF should be clear and colorless. Pink, blood-tinged, or grossly bloody CSF may indicate a cerebral contusion, laceration, or subarachnoid hemorrhage. Sometimes with a difficult lumbar puncture, the CSF initially is bloody because of local trauma but then becomes clearer. Usually, specimens are obtained for cell count, culture, and glucose and protein testing. The specimens should be sent to the laboratory immediately because changes will take place and alter
the result if the specimens are allowed to stand. (See Appendix B for the normal values of CSF.)
Post–Lumbar Puncture Headache A post–lumbar puncture headache, ranging from mild to severe, may appear a few hours to several days after the procedure. This is the most common complication, occurring in 15% to 30% of patients (Connolly, 1999). It is a throbbing bifrontal or occipital headache, dull and deep in character. It is particularly severe on sitting or standing but lessens or disappears when the patient lies down. The headache is caused by CSF leakage at the puncture site. The fluid continues to escape into the tissues by way of the needle track from the spinal canal. It is then absorbed promptly by the lymphatics. As a result of this leak, the supply of CSF in the cranium is depleted to a point at which it is insufficient to maintain proper mechanical stabilization of the brain. This leakage of CSF allows settling of the brain when the patient assumes an upright position, producing tension and stretching the venous sinuses and pain-sensitive structures. Both traction and pain are lessened and the leakage is reduced when the patient lies down. Post–lumbar puncture headache may be avoided if a smallgauge needle is used and if the patient remains prone after the procedure. When a large volume of fluid (more than 20 mL) is removed, the patient is positioned prone for 2 hours, then flat in a side-lying position for 2 to 3 hours, and then supine or prone for 6 more hours. Keeping the patient flat overnight may reduce the incidence of headaches. The postpuncture headache is usually managed by bed rest, analgesic agents, and hydration (Connolly, 1999). Occasionally, if the headache persists, the epidural blood patch technique may be used. Blood is withdrawn from the antecubital vein and injected into the epidural space, usually at the site of the previous spinal puncture. The rationale is that the blood acts as a gelatinous plug to seal the hole in the dura, preventing further loss of CSF.
Other Complications of Lumbar Puncture Herniation of the intracranial contents, spinal epidural abscess, spinal epidural hematoma, and meningitis are rare but serious complications of lumbar puncture. Other complications include temporary voiding problems, slight elevation of temperature, backache or spasms, and stiffness of the neck.
HOME AND COMMUNITY-BASED CARE Teaching Patients Self-Care Many diagnostic tests that were once performed as part of a hospital stay are now carried out in short-procedure units or outpatient testing settings or units. As a result, family members often provide the postprocedure care. Therefore, the patient and family must receive clear verbal and written instructions about precautions to take after the procedure, complications to watch for, and steps to take if complications occur. Because many patients undergoing neurologic diagnostic studies are elderly or have neurologic deficits, provisions must be made to ensure that transportation and postprocedure care and monitoring are available.
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Chart 60-4
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Guidelines for Assisting with a Lumbar Puncture
A needle is inserted into the subarachnoid space through the third and fourth or fourth and fifth lumbar interface to withdraw spinal fluid. Preprocedure 1. Determine whether written consent for the procedure has been obtained. 2. Explain the procedure to the patient and describe sensations that are likely during the procedure (ie, a sensation of cold as the site is cleansed with solution, a needle prick when local anesthetic is injected). 3. Determine whether the patient has any questions or misconceptions about the procedure; reassure the patient that the needle will not enter the spinal cord or cause paralysis. 4. Instruct the patient to void before the procedure. Procedure (performed by the physician) 1. The patient is positioned on one side at the edge of the bed or examining table with back toward the physician; the thighs and legs are flexed as much as possible to increase the space between the spinous processes of the vertebrae, for easier entry into the subarachnoid space.
5. The nurse describes the procedure step by step to the patient as it proceeds. 6. The physician cleanses the puncture site with an antiseptic solution and drapes the site. 7. Local anesthetic is injected to numb the puncture site, and then a spinal needle is inserted into the subarachnoid space through the third and fourth or fourth and fifth lumbar interspace. 8. A specimen of CSF is removed and usually collected in three test tubes, labeled in order of collection. A pressure reading may be obtained. The needle is withdrawn. 9. A small dressing is applied to the puncture site. 10. The tubes of CSF are sent to the laboratory immediately. Postprocedure 1. Instruct the patient to lie prone for 2 to 3 hours to separate the alignment of the dural and arachnoid needle punctures in the meninges, to reduce leakage of CSF.
Third lumbar vertebra
Dura mater Subarachnoid space Cauda equina
© B. Proud.
2. A small pillow may be placed under the patient’s head to maintain the spine in a horizontal position; a pillow may be placed between the legs to prevent the upper leg from rolling forward. 3. The nurse assists the patient to maintain the position to avoid sudden movement, which can produce a traumatic (bloody) tap. 4. The patient is encouraged to relax and is instructed to breathe normally, because hyperventilation may lower an elevated pressure.
Continuing Care Contacting the patient and family after diagnostic testing enables the nurse to determine whether they have any questions about the procedure or whether the patient had any untoward results. During these phone calls, teaching is reinforced and the patient and family are reminded to make and keep follow-up appointments. Patients, family members, and health care providers are focused on the immediate needs, issues, or deficits that necessitated the diagnostic testing. This is also a good time to remind them of the need for and importance of continuing health promotion and screening practices and make referrals to appropriate health care providers.
2. Monitor the patient for complications of lumbar puncture; notify physician if complications occur. 3. Encourage increased fluid intake to reduce the risk of postprocedure headache.
? 1.
Critical Thinking Exercises
A 68-year old patient with a long history of type 1 diabetes is admitted to the hospital to rule out an ischemic stroke and is scheduled for an MRI. Explain why the MRI is indicated for this patient and what, if any, precautions must be taken because this patient is diabetic. What nursing observations and assessments are indicated because of the occurrence of these two disorders? What safety precautions are essential in the MRI suite, and why?
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2.
Your clinic patient will be having an EEG. Describe the procedure, its duration, and preparation for this test, including medication/diet restrictions, if any. How would the presence of a seizure disorder alter your plan of care?
3.
Your patient is scheduled to undergo digital subtraction angiography (DSA). He tells you that he recently had an angiogram. What explanation can you give to the patient and his wife regarding the difference between the two procedures? What additional information will help prepare the patient to undergo this procedure?
REFERENCES AND SELECTED READINGS Books Bickley, L. S. & Szilagyi, P. G. (1999). Bates’ guide to physical examination and history taking (7th ed.). Philadelphia: Lippincott Williams & Wilkins. Bradley, W., Daroff, R., Fenichel, R., & Marsden, C. (Eds.). (2000). Neurology in clinical practice (vol. II, 3d ed.). Boston: Butterworth Heineman. Fischbach, F. (2002). Common laboratory and diagnostic tests (3d ed.). Philadelphia: Lippincott Williams & Wilkins. Gilman, S. (1999). Clinical examination of the nervous system. New York: McGraw-Hill. Gjedde, A., Hansen, S., Knudsen, G., & Paulson, O. (Eds.). (2001). Physiological imaging of the brain with PET. San Diego: Academic Press. Goetz, C. G., & Pappert, E. J. (1999). Textbook of clinical neurology. Philadelphia: W. B. Saunders. Greenberg, D. A., Aminoff, M., & Simon, R. (2002). Clinical neurology (5th ed.). Stamford, CT: Lange Medical Books, McGraw Hill. Herndon, R. M. (1997). Handbook of neurological rating scales. New York: Demos Vermande. Hickey, J. (2003). Clinical practice of neurologic and neurosurgical nursing (5th ed.). Philadelphia: Lippincott Williams & Wilkins. Joynt, R., Griggs, R., & Haerer, A. (2000). Baker’s clinical neurology on CD-ROM. Philadelphia: Lippincott Williams & Wilkins. Kaye, J., & Quinn, J. (2000). Clinical changes associated with normal aging. In C. M. Clark & J. Trojanowski (eds.), Neurodegenerative dementias. New York: McGraw-Hill. Loeser, J., Butler, S. H., Chapman, P. C., et al. (ed.). (2000). Bonica’s management of pain (3d ed.). Philadelphia: Lippincott Williams & Wilkins. Lueckenotte, A. (2000). Gerontological nursing (2d ed.). St Louis: Mosby.
Rowland, L. (2000). Merritts’ neurology (10th ed.). Philadelphia: Lippincott Williams & Wilkins. Shellock, F. (2001). Magnetic resonance procedures: Health effects and safety. New York: CRC Press. Stewart-Amidei, C., & Kunkel, J. (2001). AANN’s neuroscience nursing: Human responses to neurologic dysfunction (2nd ed.). Philadelphia: W. B. Saunders. Weiner, L., Levitt, L. P., Rae-Grant, A., & Weiner, H. L. (1999). Neurology (6th ed.). Philadelphia: Lippincott Williams & Wilkins.
Journals Asterisks indicate nursing research articles. Bateman, D. (2001). Neurological assessment of coma. Journal of Neurology, Neurosurgery and Psychiatry, 71, Suppl 1, i13–i17. Blows, W. (2000). Neurotransmitters of the brain: Serotonin noradrenaline, norepinephrine, and dopamine.Journal of Neuroscience Nursing, 32(4), 234–238. Connolly, M. (1999). Postdural puncture headache. American Journal of Nursing, 99(11), 48–49. Cunning, S. (1999). Preventing secondary brain injuries. Dimensions in Critical Care Nursing, 18(5), 20–22. Downey, D., & Leigh R. (1998). Eye movements: Pathophysiology, examination and clinical importance. Journal of Neuroscience Nursing, 30(1), 15–24. Falyar, C. (1999). Using transcranial Doppler sonography to augment the neurology examination after aneurysmal subarachnoid hemorrhage. Journal of Neuroscience Nursing, 31(5), 285–293. Frizzell, J. (1998). Cerebral angiography. American Journal of Nursing, 98(9), 16II-16JJ. Hinkle, J. (1999a). CT scanning. American Journal of Nursing, 99(6), 24AA–24FF. Hinkle, J. (1999b). Magnetic resonance imaging. American Journal of Nursing, 99(11), 24CC–24JJ. Huntington, N. (1999). The nurse’s role in delivery of radioisotope for ictal SPECT scan. Journal of Neuroscience Nursing, 31(4), 208–215. Johnson, M. (2001). Assessing confused patients. Journal of Neurology, Neurosurgery and Psychiatry, 71, Suppl. 1, i7–i12. King, D. (1999). Central nervous system infections: Basic concepts. Nursing Clinics of North America, 34(3), 761–771. O’Hanlon-Nichols, T. (1999). Neurologic assessment. American Journal of Nursing, 99(6), 44–50. *Rapp, C., Wakefield, B., Kundrat, M., et al. (2000). Acute confusion assessment instruments: Clinical versus research usability. Applied Nursing Research, 13(1), 37–45. *Souder, E., & O’Sullivan, P. (2000). Nursing documentation versus standardized assessment of cognitive status in hospitalized medical patients. Applied Nursing Research, 13(1), 29–36. Stewart-Amidei, C. (1998). Neurologic monitoring in the ICU. Critical Care Nursing Quarterly, 21(3), 47–60. Sullivan, J. (1999). Determining brain death. Critical Care Nursing, 19(2), 37–46.
Chapter
61 ●
Management of Patients With Neurologic Dysfunction
LEARNING OBJECTIVES
●
On completion of this chapter, the learner will be able to: 1. Describe the special nursing needs of patients with varied neuro2. 3. 4. 5. 6. 7. 8. 9. 10.
logic dysfunction. Describe the multiple needs of the patient with altered level of consciousness. Use the nursing process as a framework for care of the patient with altered level of consciousness. Identify the early and late clinical manifestations of increased intracranial pressure. Use the nursing process as a framework for care of the patient with increased intracranial pressure. Describe the needs of the patient undergoing intracranial or transsphenoidal surgery. Use the nursing process as a framework for care of the patient undergoing intracranial/transsphenoidal surgery. Identify the various types and causes of seizures. Use the nursing process to develop a plan of care for the patient experiencing seizures. Identify the needs of the patient experiencing headaches.
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his chapter discusses care of the patient with an altered level of consciousness, the patient with increased intracranial pressure (ICP), and the patient undergoing neurosurgical procedures, experiencing seizures, or experiencing headaches. Some of the topics in this chapter, such as headaches and seizures, may be symptoms of dysfunction in another body system. Conversely, headaches and seizures can be quite serious symptoms of a severe disruption of the neurologic system. These disorders can also be diagnosed at times as “idiopathic,” or without an identifiable cause. The commonality in these disorders is not in the diagnosis or the medical treatment; it is in the behaviors and needs of the patient and the manner in which nurses can best support the patient through these episodes. The central nervous system contains a vast network of neurons controlling the body’s vital functions. Yet this system is vulnerable, and its optimal function depends on several key factors. First, the neurologic system relies on its own structural integrity for support and homeostasis. Examples of structural disruption include head injury, brain tumor, intracranial hemorrhage, infection, and stroke. As brain tissue expands in the inflexible cranium, ICP rises and cerebral perfusion is impaired. Further expansion places pressure on vital centers, which can cause permanent neurologic deficits or lead to brain death. Second, the neurologic system also relies on the body’s ability to maintain a homeostatic environment. It requires the body to deliver the essential elements of oxygen and glucose and to filter out substrates toxic to the neurons. Sepsis, hypovolemia, myocardial infarction, respiratory arrest, hypoglycemia, electrolyte imbalance, drug and/or alcohol overdose, encephalopathy, and ketoacidosis are all examples of circumstances in which the neurologic system is depressed due to a toxic metabolic effect or due to the body’s mechanical inability to provide essential substrates.
Some conditions can be treated and neurologic impairments can be reversed; others result in permanent deficits. Although neuroscience nursing is a specialty requiring an understanding of neuroanatomy, neurophysiology, neurodiagnostic testing, critical care nursing, and rehabilitation nursing, nurses in all settings care for patients with neurologic disorders. Ongoing assessment of the patient’s neurologic function and health needs, identification of problems, mutual goal setting, development and implementation of care plans (including teaching, counseling, and coordinating activities), and evaluation of the outcomes of care are nursing actions integral to the recovery of the patient. The nurse also collaborates with other members of the health care team to provide essential care, offer a variety of solutions to problems, help patients and families gain control of their lives, and explore the educational and supportive resources available in the community. The goals are to achieve as high a level of function as possible and to enhance the quality of life for the patient with neurologic impairment and his or her family.
Altered Level of Consciousness An altered level of consciousness (LOC) is apparent in the patient who is not oriented, does not follow commands, or needs persistent stimuli to achieve a state of alertness. LOC is gauged on a continuum with a normal state of alertness and full cognition (consciousness) on one end and coma on the other end. Coma is a clinical state of unconsciousness in which the patient is unaware of self or the environment for prolonged periods (days to months or even years). Akinetic mutism is a state of unresponsiveness to the environment in which the patient makes no movement or sound but sometimes opens the eyes. Persistent vegetative state is a condition in which the patient is described as wakeful but de-
Glossary akinetic mutism: unresponsiveness to the environment; the patient makes no movement or sound but sometimes opens the eyes altered level of consciousness: condition of being less responsive to and aware of environmental stimuli autoregulation: ability of cerebral blood vessels to dilate or constrict to maintain stable cerebral blood flow despite changes in systemic arterial blood pressure brain death: irreversible loss of all functions of the entire brain, including the brain stem coma: prolonged state of unconsciousness craniotomy: a surgical procedure that involves entry into the cranial vault craniectomy: a surgical procedure that involves removing a portion of the skull Cushing’s response: brain’s attempt to restore blood flow by increasing arterial pressure to overcome the increased intracranial pressure Cushing’s triad: three classic signs— bradycardia, hypertension, and bradypnea— seen with pressure on the medulla as a result of brain stem herniation decerebration: an abnormal body posture associated with a severe brain injury, char-
acterized by extreme extension of the upper and lower extremities decortication: an abnormal posture associated with severe brain injury, characterized by abnormal flexion of the upper extremities and extension of the lower extremities epidural monitor: a sensor placed between the skull and the dura to monitor intracranial pressure epilepsy: a group of syndromes characterized by paroxysmal transient disturbances of brain function. fiberoptic monitor: a system that uses light refraction to determine intracranial pressure herniation: abnormal protrusion of tissue through a defect or natural opening intracranial pressure: pressure exerted by the volume of the intracranial contents within the cranial vault migraine headache: a severe, unrelenting headache often accompanied by symptoms such as nausea, vomiting, and visual disturbances Monro-Kellie hypothesis: theory that states that due to limited space for expansion within the skull, an increase in any one of
the cranial contents—brain tissue, blood, or CSF—causes a change in the volume of the others persistent vegetative state: condition in which the patient is wakeful but devoid of conscious content, without cognitive or affective mental function primary headache: a headache for which no specific organic cause can be found seizures: paroxysmal transient disturbance of the brain resulting from a discharge of abnormal electrical activity status epilepticus: episode in which the patient experiences multiple seizure bursts with no recovery time in between secondary headache: headache identified as a symptom of another organic disorder (eg, brain tumor, hypertension) subarachnoid screw or bolt: device placed into the subarachnoid space to measure intracranial pressure transsphenoidal: surgical approach to the pituitary via the sphenoid sinuses ventriculostomy: a catheter placed in one of the lateral ventricles of the brain to measure intracranial pressure and allow for drainage of fluid
Chapter 61 void of conscious content, without cognitive or affective mental function. The level of responsiveness and consciousness is the most important indicator of the patient’s condition.
Pathophysiology Altered LOC is not a disorder itself; rather, it is a function and symptom of multiple pathophysiologic phenomena. The cause may be neurologic (head injury, stroke), toxicologic (drug overdose, alcohol intoxication), or metabolic (hepatic or renal failure, diabetic ketoacidosis). The underlying causes of neurologic dysfunction are disruption in the cells of the nervous system, neurotransmitters, or brain anatomy (see Chap. 60). A disruption in the basic functional units (neurons) or neurotransmitters results in faulty impulse transmission, impeding communication within the brain or from the brain to other parts of the body. These disruptions are caused by cellular edema and other mechanisms such as antibodies disrupting chemical transmission at receptor sites. Intact anatomic structures of the brain are needed for proper function. The two hemispheres of the cerebrum must communicate, via an intact corpus callosum, and the lobes of the brain (frontal, parietal, temporal, and occipital) must communicate and coordinate their specific functions (see Chap. 60). Additional anatomic structures of importance are the cerebellum and the brain stem. The cerebellum has both excitatory and inhibitory actions and is largely responsible for coordination of movement. The brain stem contains areas that control the heart, respiration, and blood pressure. Disruptions in the anatomic structures are caused by trauma, edema, pressure from tumors as well as other mechanisms such as an increase or decrease in blood or cerebrospinal fluid (CSF) circulation.
Clinical Manifestations Alterations in LOC occur along a continuum, and the clinical manifestations depend on where the patient is along this continuum. As the patient’s state of alertness and consciousness decreases, there will be changes in the pupillary response, eye opening response, verbal response, and motor response. Initial changes may be reflected by subtle behavioral changes such as restlessness or increased anxiety. The pupils, normally round and quickly reactive to light, become sluggish (response is slower); as the patient becomes comatose, the pupils become fixed (no response to light). The patient in a coma does not open the eyes, respond verbally, or move the extremities in response to a request to do so.
Assessment and Diagnostic Findings The patient with an altered LOC is at risk for alterations in every body system. A complete assessment is performed, with particular attention to the neurologic system. The neurologic examination should be as complete as the LOC allows. It includes an evaluation of mental status, cranial nerve function, cerebellar function (balance and coordination), reflexes, and motor and sensory function. LOC, a sensitive indicator of neurologic function, is assessed based on the criteria in the Glasgow Coma Scale: eye opening, verbal response, and motor response (Bateman, 2001). The patient’s responses are rated on a scale from 3 to 15. A score of 3 indicates severe impairment of neurologic function; a score of 15 indicates that the patient is fully responsive (see Chap. 63 for more discussion about the Glasgow Coma Scale).
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If the patient is comatose, with localized signs such as abnormal pupillary and motor responses, it is assumed that neurologic disease is present until proven otherwise. If the patient is comatose and pupillary light reflexes are preserved, a toxic or metabolic disorder is suspected. Procedures used to identify the cause of unconsciousness include scanning, imaging, tomography (eg, computed tomography, magnetic resonance imaging, positron emission tomography), and electroencephalography. Laboratory tests include analysis of blood glucose, electrolytes, serum ammonia, and blood urea nitrogen levels, as well as serum osmolality, calcium level, and partial thromboplastin and prothrombin times. Other studies may be used to evaluate serum ketones and alcohol, drug levels, and arterial blood gas levels.
Complications Potential complications for the patient with altered LOC include respiratory failure, pneumonia, pressure ulcers, and aspiration. Respiratory failure may develop shortly after the patient becomes unconscious. If the patient cannot maintain effective respirations, supportive care is initiated to provide adequate ventilation. Pneumonia is common in patients receiving mechanical ventilation or in those who cannot maintain and clear the airway. The patient with altered LOC is subject to all the complications associated with immobility, such as pressure ulcers, venous stasis, musculoskeletal deterioration, and disturbed gastrointestinal functioning. Pressure ulcers may become infected and act as a source of sepsis. Aspiration of gastric contents or feedings may occur, precipitating the development of pneumonia or airway occlusion.
Medical Management The first priority of treatment for the patient with altered LOC is to obtain and maintain a patent airway. The patient may be orally or nasally intubated, or a tracheostomy may be performed. Until the patient’s ability to breathe on his or her own is determined, a mechanical ventilator is used to maintain adequate oxygenation. The circulatory status (blood pressure, heart rate) is monitored to ensure adequate perfusion to the body and brain. An intravenous catheter is inserted to provide access for fluids and intravenous medications. Neurologic care focuses on the specific neurologic pathology, if any. Nutritional support, using either a feeding tube or a gastrostomy tube, is initiated as soon as possible. In addition to measures to determine and treat the underlying causes of altered LOC, other medical interventions are aimed at pharmacologic management of complications and strategies to prevent complications.
NURSING PROCESS: THE PATIENT WITH AN ALTERED LEVEL OF CONSCIOUSNESS Assessment Where to begin assessing the patient with an altered LOC depends somewhat on each patient’s circumstances, but clinicians often start by assessing the verbal response. Determining the patient’s orientation to time, person, and place assesses verbal response. The patient is asked to identify the day, date, or season of the year and to identify where he or she is or to identify the clinicians, family members, or visitors present. Other questions such as, “Who is the president?” or “What is the next holiday?”
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are also helpful in determining the patient’s processing of information in the environment. (Verbal response cannot be evaluated when the patient is intubated or has a tracheostomy, and this should be clearly documented.) Alertness is measured by the patient’s ability to open the eyes spontaneously or to a stimulus. Patients with severe neurologic dysfunction cannot do this. The nurse should assess for periorbital edema or trauma, which may prevent the patient from opening the eyes, and document if this interferes with eye opening. Motor response includes spontaneous, purposeful movement (eg, the awake patient can move all four extremities with equal strength), movement only in response to noxious stimuli (eg, pressure/pain), or abnormal posturing (Bateman, 2001). If the patient is not responding to commands, the motor response is tested by applying a painful stimulus (firm but gentle pressure) to the nailbed or by squeezing a muscle. If the patient attempts to push away or withdraw, the response is recorded as purposeful or appropriate (“patient withdraws to painful stimuli”). This response is considered purposeful if the patient can cross from one side of the body to the other in response to noxious stimuli. An inappropriate or nonpurposeful response is random and aimless. Posturing may be decorticate or decerebrate (Fig. 61-1; see Chap. 60). The most severe neurologic impairment results in flaccidity. Occasionally, posturing cannot be elicited if the patient has been given pharmacologic paralyzing agents. In addition to LOC, the nurse monitors parameters such as respiratory status, eye signs, and reflexes on an ongoing basis. Table 61-1 summarizes the assessment and the clinical significance of the findings. Body functions (circulation, respiration, elimination, fluid and electrolyte balance) are examined in a systematic and ongoing manner.
Diagnosis NURSING DIAGNOSES Based on the assessment data, the major nursing diagnoses may include the following:
• Ineffective airway clearance related to altered level of consciousness
• Risk of injury related to decreased level of consciousness • Deficient fluid volume related to inability to take in fluids by mouth
• Impaired oral mucous membranes related to mouth• • • • • • •
breathing, absence of pharyngeal reflex, and altered fluid intake Risk for impaired skin integrity related to immobility Impaired tissue integrity of cornea related to diminished or absent corneal reflex Ineffective thermoregulation related to damage to hypothalamic center Impaired urinary elimination (incontinence or retention) related to impairment in neurologic sensing and control Bowel incontinence related to impairment in neurologic sensing and control and also related to transitions in nutritional delivery methods Disturbed sensory perception related to neurologic impairment Interrupted family processes related to health crisis
COLLABORATIVE PROBLEMS/ POTENTIAL COMPLICATIONS Based on the assessment data, potential complications may include:
• • • • •
Respiratory distress or failure Pneumonia Aspiration Pressure ulcer Deep vein thrombosis
Planning and Goals The goals of care for the patient with altered LOC include maintenance of a clear airway, protection from injury, attainment of fluid volume balance, achievement of intact oral mucous membranes, maintenance of normal skin integrity, absence of corneal irritation, attainment of effective thermoregulation, and effective urinary elimination. Additional goals include bowel continence, accurate perception of environmental stimuli, maintenance of intact family or support system, and absence of complications (Jacobson & Winslow, 2000). Because the unconscious patient’s protective reflexes are impaired, the quality of nursing care provided literally may mean the difference between life and death. The nurse must assume responsibility for the patient until the basic reflexes (coughing, blinking, and swallowing) return and the patient becomes conscious and oriented. Thus, the major nursing goal is to compensate for the absence of these protective reflexes.
Flexed
A Plantar flexed
Internally rotated
Flexed
Adducted
FIGURE 61-1
B Plantar flexed
Flexed
Pronated
Extended
Adducted
Abnormal posture response to stimuli. (A) Decorticate posturing, involving adduction and flexion of the upper extremities, internal rotation of the lower extremities, and plantar flexion of the feet. (B) Decerebrate posturing, involving extension and outward rotation of upper extremities and plantar flexion of the feet.
Table 61-1
• Nursing Assessment of the Unconscious Patient
EXAMINATION
CLINICAL ASSESSMENT
CLINICAL SIGNIFICANCE
Level of responsiveness or consciousness Pattern of respiration
Eye opening; verbal and motor responses; pupils (size, equality, reaction to light) Respiratory pattern
Ataxic respiration with irregularity in depth/rate
Obeying commands is a favorable response and demonstrates a return to consciousness. Disturbances of respiratory center of brain may result in various respiratory patterns. Suggests lesions deep in both hemispheres; area of basal ganglia and upper brain stem Suggests onset of metabolic problem or brain stem damage Ominous sign of damage to medullary center
Equal, normally reactive pupils Equal or unequal diameter Progressive dilation Fixed dilated pupils
Suggests that coma is toxic or metabolic in origin Helps determine location of lesion Indicates increasing ICP Indicates injury at level of midbrain
Eye movements
Normally, eyes should move from side to side.
Corneal reflex
When cornea is touched with a wisp of clean cotton, blink response is normal.
Functional and structural integrity of brain stem is assessed by inspection of extraocular movements; usually absent in deep coma. Tests cranial nerves V and VII; helps determine location of lesion if unilateral; absent in deep coma
Cheyne-Stokes respiration Hyperventilation Eyes Pupils (size, equality, reaction to light)
Facial symmetry Swallowing reflex
Asymmetry (sagging, decrease in wrinkles) Drooling versus spontaneous swallowing
Neck
Stiff neck Absence of spontaneous neck movement Firm pressure on a joint of the upper and lower extremity Observe spontaneous movements. Tap patellar and biceps tendons.
Response of extremity to noxious stimuli Deep tendon reflexes Pathologic reflexes
Firm pressure with blunt object on sole of foot, moving along lateral margin and crossing to the ball of foot
Abnormal posture
Observation for posturing (spontaneous or in response to noxious stimuli) Flaccidity with absence of motor response Decorticate posture (flexion and internal rotation of forearms and hands) Decerebrate posture (extension and external rotation)
Sign of paralysis Absent in coma Paralysis of cranial nerves X and XII Subarachnoid hemorrhage, meningitis Fracture or dislocation of cervical spine Asymmetric response in paralysis Absent in deep coma Brisk response may have localizing value. Asymmetric response in paralysis Absent in deep coma Flexion of the toes, especially the great toe, is normal except in newborn. Dorsiflexion of toes (especially great toe) indicates contralateral pathology of corticospinal tract (Babinski reflex). Helps determine location of lesion in brain
Deep extensive brain lesion Seen with cerebral hemisphere pathology and in metabolic depression of brain function Decerebrate posturing indicates deeper and more severe dysfunction than does decorticate posturing; implies brain pathology; poor prognostic sign. 1853
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Nursing Interventions MAINTAINING THE AIRWAY The most important consideration in managing the patient with altered LOC is to establish an adequate airway and ensure ventilation. Obstruction of the airway is a risk because the epiglottis and tongue may relax, occluding the oropharynx, or the patient may aspirate vomitus or nasopharyngeal secretions. The accumulation of secretions in the pharynx presents a serious problem. Because the patient cannot swallow and lacks pharyngeal reflexes, these secretions must be removed to eliminate the danger of aspiration. Elevating the head of the bed to 30 degrees helps prevent aspiration. Positioning the patient in a lateral or semiprone position will also help as it permits the jaw and tongue to fall forward, thus promoting drainage of secretions. Positioning alone is not always adequate, however. The patient may require suctioning and oral hygiene. Suctioning is performed to remove secretions from the posterior pharynx and upper trachea. With the suction off, a whistle-tip catheter is lubricated with a water-soluble lubricant and inserted to the level of the posterior pharynx and upper trachea. Continuous suction is applied as the catheter is withdrawn using a twisting motion of the thumb and forefinger. This twisting maneuver prevents the suctioning end of the catheter from causing irritation, which increases secretions and causes mucosal trauma and bleeding. Before and after suctioning, the patient is hyperoxygenated and hyperventilated to prevent hypoxia (Hickey, 2003). In addition to these interventions, chest physiotherapy and postural drainage may be initiated to promote pulmonary hygiene, unless contraindicated by the patient’s underlying condition. Also, the chest should be auscultated at least every 8 hours to detect adventitious breath sounds or absence of breath sounds. Despite these measures, or because of the severity of impairment, the patient with altered LOC often requires intubation and mechanical ventilation. Nursing actions for the mechanically ventilated patient include maintaining the patency of the endotracheal tube or tracheostomy, providing frequent oral care, monitoring arterial blood gas measurements, and maintaining ventilator settings (see Chap. 25). PROTECTING THE PATIENT For the protection of the patient, padded siderails are provided and raised at all times. Care should be taken to prevent injury from invasive lines and equipment, and other potential sources of injury should be identified (eg, restraints, tight dressings, environmental irritants, damp bedding or dressings, tubes and drains).
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NURSING ALERT If the patient begins to emerge from unconsciousness, every measure that is available and appropriate for calming and quieting him or her should be used. Any form of restraint is likely to be countered by the patient with resistance, leading to self-injury or to a dangerous increase in ICP. Therefore, physical restraints should be avoided if possible; a written prescription must be obtained if their use is essential for the patient’s well-being.
Protection also encompasses the concept of protecting the patient’s dignity during altered LOC. Simple measures such as providing privacy and speaking to the patient during nursing care activities preserve the patient’s humanity. Not speaking negatively about the patient’s condition or prognosis is also important, because patients in a light coma may be able to hear. The comatose patient has an increased need for advocacy, and it is the
nurse’s responsibility to see that these advocacy needs are met (Elliott & Wright, 1999; Villanueva, 1999). MAINTAINING FLUID BALANCE AND MANAGING NUTRITIONAL NEEDS Hydration status is assessed by examining tissue turgor and mucous membranes, assessing intake and output trends, and analyzing laboratory data. Fluid needs are met initially by giving the required fluids intravenously. However, intravenous solutions (and blood transfusions) for patients with intracranial conditions must be administered slowly. If given too rapidly, they may increase ICP. The quantity of fluids administered may be restricted to minimize the possibility of producing cerebral edema. If the patient does not recover quickly and sufficiently enough to take adequate fluids and calories by mouth, a feeding tube will be inserted for the administration of fluids and enteral feedings (Day, Stotts, Frankfurt et al., 2001). PROVIDING MOUTH CARE The mouth is inspected for dryness, inflammation, and crusting. The unconscious patient requires conscientious oral care because there is a risk of parotitis if the mouth is not kept scrupulously clean. The mouth is cleansed and rinsed carefully to remove secretions and crusts and to keep the mucous membranes moist. A thin coating of petrolatum on the lips prevents drying, cracking, and encrustations. If the patient has an endotracheal tube, the tube should be moved to the opposite side of the mouth daily to prevent ulceration of the mouth and lips. MAINTAINING SKIN AND JOINT INTEGRITY Preventing skin breakdown requires continuing nursing assessment and intervention. Special attention is given to unconscious patients because they cannot respond to external stimuli. Assessment includes a regular schedule of turning to avoid pressure, which can cause breakdown and necrosis of the skin. Turning also provides kinesthetic (sensation of movement), proprioceptive (awareness of position), and vestibular (equilibrium) stimulation. After turning, the patient is carefully repositioned to prevent ischemic necrosis over pressure areas. Dragging the patient up in bed must be avoided, because this creates a shearing force and friction on the skin surface. Maintaining correct body position is important; equally important is passive exercise of the extremities to prevent contractures. The use of splints or foam boots aids in the prevention of footdrop and eliminates the pressure of bedding on the toes. Trochanter rolls supporting the hip joints keep the legs in proper alignment. The arms should be in abduction, the fingers lightly flexed, and the hands in slight supination. The heels of the feet should be assessed for pressure areas. Specialty beds, such as fluidized or low-air-loss beds, may be used to decrease pressure on bony prominences. PRESERVING CORNEAL INTEGRITY Some unconscious patients have their eyes open and have inadequate or absent corneal reflexes. The cornea is likely to become irritated or scratched, leading to keratitis and corneal ulcers. The eyes may be cleansed with cotton balls moistened with sterile normal saline to remove debris and discharge. If artificial tears are prescribed, they may be instilled every 2 hours. Periocular edema (swelling around the eyes) often occurs after cranial surgery. Cold compresses may be prescribed, and care must be exerted to avoid contact with the cornea. Eye patches should be used cautiously
Chapter 61 because of the potential for corneal abrasion from the cornea coming in contact with the patch. ACHIEVING THERMOREGULATION High fever in the unconscious patient may be caused by infection of the respiratory or urinary tract, drug reactions, or damage to the hypothalamic temperature-regulating center. A slight elevation of temperature may be caused by dehydration. The environment can be adjusted, depending on the patient’s condition, to promote a normal body temperature. If body temperature is elevated, a minimum amount of bedding—a sheet or perhaps only a small drape—is used. The room may be cooled to 18.3°C (65°F). However, if the patient is elderly and does not have an elevated temperature, a warmer environment is needed.
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NURSING ALERT The body temperature of an unconscious patient is never taken by mouth. Rectal or tympanic (if not contraindicated) temperature measurement is preferred to the less accurate axillary temperature.
Because of damage to the heat-regulating center in the brain or severe intracranial infection, unconscious patients often develop very high temperatures. Such temperature elevations must be controlled because the increased metabolic demands of the brain can overburden cerebral circulation and oxygenation, resulting in cerebral deterioration (Hickey, 2003). Persistent hyperthermia with no identified clinical source of infection indicates brain stem damage and a poor prognosis. Strategies for reducing fever include:
• Removing all bedding over the patient (with the possible exception of a light sheet or small drape)
• Administering repeated doses of acetaminophen as prescribed
• Giving a cool sponge bath and allowing an electric fan to blow over the patient to increase surface cooling
• Using a hypothermia blanket Frequent temperature monitoring is indicated to assess the response to the therapy and to prevent an excessive decrease in temperature and shivering. PREVENTING URINARY RETENTION The patient with an altered LOC is often incontinent or has urinary retention. The bladder is palpated or scanned at intervals to determine whether urinary retention is present, because a full bladder may be an overlooked cause of overflow incontinence. A portable bladder ultrasound instrument is a useful tool in bladder management and retraining programs (O’Farrell, Vandervoort, Bisnaire et al., 2001). If there are signs of urinary retention, initially an indwelling urinary catheter attached to a closed drainage system is inserted. A catheter may be inserted during the acute phase of illness to monitor urinary output. Because catheters are a major factor in causing urinary tract infection, the patient is observed for fever and cloudy urine. The area around the urethral orifice is inspected for drainage. The urinary catheter is usually removed when the patient has a stable cardiovascular system and if no diuresis, sepsis, or voiding dysfunction existed before the onset of coma. Although many unconscious patients urinate spontaneously after catheter removal, the bladder should be palpated or scanned with a portable ultrasound device periodically for urinary retention (O’Farrell et al., 2001). An intermittent catheterization
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program may be initiated to ensure complete emptying of the bladder at intervals, if indicated. An external catheter (condom catheter) for the male patient and absorbent pads for the female patient can be used for the unconscious patient who can urinate spontaneously although involuntarily. As soon as consciousness is regained, a bladder-training program is initiated. The incontinent patient is monitored frequently for skin irritation and skin breakdown. Appropriate skin care is implemented to prevent these complications. PROMOTING BOWEL FUNCTION The abdomen is assessed for distention by listening for bowel sounds and measuring the girth of the abdomen with a tape measure. There is a risk of diarrhea from infection, antibiotics, and hyperosmolar fluids. Frequent loose stools may also occur with fecal impaction. Commercial fecal collection bags are available for patients with fecal incontinence. Immobility and lack of dietary fiber may cause constipation. The nurse monitors the number and consistency of bowel movements and performs a rectal examination for signs of fecal impaction. Stool softeners may be prescribed and can be administered with tube feedings. To facilitate bowel emptying, a glycerine suppository may be indicated. The patient may require an enema every other day to empty the lower colon. PROVIDING SENSORY STIMULATION Sensory stimulation is provided at the appropriate time to help overcome the profound sensory deprivation of the unconscious patient. Efforts are made to maintain the sense of daily rhythm by keeping the usual day and night patterns for activity and sleep. The nurse touches and talks to the patient and encourages family members and friends to do so. Communication is extremely important and includes touching the patient and spending enough time with him or her to become sensitive to his or her needs. It is also important to avoid making any negative comments about the patient’s status or prognosis in the patient’s presence. The nurse orients the patient to time and place at least once every 8 hours. Sounds from the patient’s home and workplace may be introduced using a tape recorder. Family members can read to the patient from a favorite book and may suggest radio and television programs that the patient previously enjoyed as a means of enriching the environment and providing familiar input (Hickey, 2003). When arousing from coma, many patients experience a period of agitation, indicating that they are becoming more aware of their surroundings but still cannot react or communicate in an appropriate fashion. Although disturbing for many family members, this is actually a good clinical sign. At this time, it is necessary to minimize the stimulation to the patient by limiting background noises, having only one person speak to the patient at a time, giving the patient a longer period of time to respond, and allowing for frequent rest or quiet times. When the patient has regained consciousness, videotaped family or social events may assist the patient in recognizing family and friends and allow him or her to experience missed events. MEETING FAMILIES’ NEEDS The family of the patient with altered LOC may be thrown into a sudden state of crisis and go through the process of severe anxiety, denial, anger, remorse, grief, and reconciliation. Depending on the disorder that caused the altered LOC and the extent of the patient’s recovery, the family may be unprepared for the changes in the cognitive and physical status of their loved one. If the
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patient has significant residual deficits, the family may require considerable time, assistance, and support to come to terms with these changes. To help family members mobilize their adaptive capacities, the nurse can reinforce and clarify information about the patient’s condition, permit the family to be involved in care, and listen to and encourage ventilation of feelings and concerns while supporting them in their decision-making process about posthospitalization management and placement (Hauber & Testani-Dufour, 2000). Families may benefit from participation in support groups offered through the hospital, rehabilitation facility, or community organizations. In some circumstances, the family may need to face the death of their loved one. The neurologic patient is often pronounced brain dead before physiologic death occurs. The term brain death describes irreversible loss of all functions of the entire brain, including the brain stem. The term may be misleading to the family because although brain function has ceased, the patient appears to be alive, with the heart rate and blood pressure sustained by vasoactive medications, and breathing continues by mechanical ventilation. When discussing a patient who is brain dead with family members, it is important to use the term “dead”; the term “brain dead” may confuse them (Shewmon, 1998). Chart 61-1 discusses ethical issues related to patients with severe neurologic damage. End-of-life care is discussed in Chapter 17. MONITORING AND MANAGING POTENTIAL COMPLICATIONS Pneumonia, aspiration, and respiratory failure are potential complications in any patient who has a depressed LOC and who cannot protect the airway or turn, cough, and take deep breaths. The longer the period of unconsciousness, the greater the risk for pulmonary complications. Vital signs and respiratory function are monitored closely to detect any signs of respiratory failure or distress. Total blood
Chart 61-1
• Ethics and Related Issues
What Ethical Principles Apply When Treatment Is Withdrawn From the Patient in a Persistent Vegetative State? Situation The family of a 55-year-old woman who has been diagnosed as being in a persistent vegetative state wants to withdraw tube feedings and let her die. The nursing staff express concern about removing the feeding tube, relating that the patient has wakeful periods and sometimes seems to move her eyes toward them when they care for her. The family’s wishes, however, are honored and the medical team discontinues all tube feedings and intravenous lines and orders comfort measures only. The patient dies 7 days later. Dilemma How do nurses reconcile their ethical obligations of respect for persons and sanctity of life in the face of a decision to withdraw treatment? Is the ethical principle of justice upheld? Discussion Is the maintenance of medical treatment obligatory in patients in a persistent vegetative state to provide respect for the patient and the sanctity of life? What mechanisms can the nursing staff use to assist them in resolving these dilemmas?
count and arterial blood gas measurements are assessed to determine whether there are adequate red blood cells to carry oxygen and whether ventilation is effective. Chest physiotherapy and suctioning are initiated to prevent respiratory complications such as pneumonia. If pneumonia develops, cultures are obtained to identify the organism so that appropriate antibiotics can be administered. The patient with altered LOC is monitored closely for evidence of impaired skin integrity, and strategies to prevent skin breakdown and pressure ulcers are continued through all phases of care, including hospital, rehabilitation, and home care. Factors that contribute to impaired skin integrity (eg, incontinence, inadequate dietary intake, pressure on bony prominences, edema) are addressed. If pressure ulcers develop, strategies to promote healing are undertaken. Care is taken to prevent bacterial contamination of pressure ulcers, which may lead to sepsis and septic shock. Assessment and management of pressure ulcers are discussed in Chapter 11. The patient should also be monitored for signs and symptoms of deep vein thrombosis. Patients who develop deep vein thrombosis are at risk for pulmonary embolism. Prophylaxis such as subcutaneous heparin or low-molecular-weight heparin (Fragmin, Orgaran) should be prescribed (Karch, 2002). Thigh-high elastic compression stockings or pneumatic compression stockings should also be prescribed to reduce the risk for clot formation. Measures to assess for deep vein thrombosis, such as Homans’ sign, may be clinically unreliable in this population, and the nurse should observe for redness and swelling in the lower extremities.
Evaluation EXPECTED PATIENT OUTCOMES Expected patient outcomes may include: 1. Maintains clear airway and demonstrates appropriate breath sounds 2. Experiences no injuries 3. Attains/maintains adequate fluid status a. Has no clinical signs or symptoms of dehydration b. Demonstrates normal range of serum electrolytes c. Has no clinical signs or symptoms of overhydration 4. Attains/maintains healthy oral mucous membranes 5. Maintains normal skin integrity 6. Has no corneal irritation 7. Attains or maintains thermoregulation 8. Has no urinary retention 9. Has no diarrhea or fecal impaction 10. Receives appropriate sensory stimulation 11. Family members cope with crisis a. Verbalize fears and concerns b. Participate in patient’s care and provide sensory stimulation by talking and touching 12. Is free of complications a. Has arterial blood gas values within normal range b. Displays no signs or symptoms of pneumonia c. Exhibits intact skin over pressure areas d. Does not develop deep vein thrombosis
Increased Intracranial Pressure The rigid cranial vault contains brain tissue (1,400 g), blood (75 mL), and CSF (75 mL) (Hickey, 2003). The volume and pressure of these three components are usually in a state of equi-
Chapter 61 librium and produce the ICP. ICP is usually measured in the lateral ventricles; normal ICP is 10 to 20 mm Hg (Hickey, 2003). The Monro-Kellie hypothesis states that because of the limited space for expansion within the skull, an increase in any one of the components causes a change in the volume of the others. Because brain tissue has limited space to change, compensation typically is accomplished by displacing or shifting CSF, increasing the absorption of CSF, or decreasing cerebral blood volume. Without such changes, ICP will begin to rise. Under normal circumstances, minor changes in blood volume and CSF volume occur constantly due to alterations in intrathoracic pressure (coughing, sneezing, straining), posture, blood pressure, and systemic oxygen and carbon dioxide levels.
Pathophysiology Increased ICP is a syndrome that affects many patients with acute neurologic conditions. This is because pathologic conditions alter the relationship between intracranial volume and pressure. Although an elevated ICP is most commonly associated with head injury, it also may be seen as a secondary effect in other conditions, such as brain tumors, subarachnoid hemorrhage, and toxic and viral encephalopathies. Increased ICP from any cause decreases cerebral perfusion, stimulates further swelling (edema), and shifts brain tissue through openings in the rigid dura, resulting in herniation, a dire, frequently fatal event. DECREASED CEREBRAL BLOOD FLOW Increased ICP may significantly reduce cerebral blood flow, resulting in ischemia and cell death. In the early stages of cerebral ischemia, the vasomotor centers are stimulated and the systemic pressure rises to maintain cerebral blood flow. Usually a slow bounding pulse and respiratory irregularities accompany this. These changes in blood pressure, pulse, and respiration are important clinically because they suggest increased ICP. The concentration of carbon dioxide in the blood and in the brain tissue also has a role in the regulation of cerebral blood flow. A rise in carbon dioxide partial pressure (PaCO2) causes cerebral vasodilatation, leading to increased cerebral blood flow and increased ICP; a fall in PaCO2 has a vasoconstrictive effect (Young, Ropper & Bolton, 1998). Decreased venous outflow may also increase cerebral blood volume, thus raising ICP. CEREBRAL EDEMA Cerebral edema or swelling is defined as an abnormal accumulation of water or fluid in the intracellular space, extracellular space,
Management of Patients With Neurologic Dysfunction
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or both, associated with an increase in brain tissue volume. Edema can occur in the gray, white, or interstitial matter. As brain tissue swells within the rigid skull, several mechanisms attempt to compensate for the increasing ICP. These mechanisms include autoregulation and decreasing the production and flow of CSF. Autoregulation refers to the brain’s ability to change the diameter of its blood vessels automatically to maintain a constant cerebral blood flow during alterations in systemic blood pressure. CEREBRAL RESPONSE TO INCREASED ICP As ICP rises, compensatory mechanisms in the brain work to maintain blood flow and prevent tissue damage. The brain can maintain a steady perfusion pressure when the arterial systolic blood pressure is 50 to 150 mm Hg and ICP is less than 40 mm Hg. The cerebral perfusion pressure is calculated by subtracting the ICP from the mean arterial pressure. For example, if the mean arterial pressure is 100 and the ICP is 15, then the cerebral perfusion pressure is 85 mm Hg. The normal cerebral perfusion pressure is 70 to 100 mm Hg (Hickey, 2003; Young et al., 1998). As ICP rises, however, and the autoregulatory mechanism of the brain is overwhelmed, cerebral perfusion pressure can rise to greater than 100 mm Hg or fall to less than 50 mm Hg. Patients with a cerebral perfusion pressure less than 50 mm Hg experience irreversible neurologic damage. If ICP equals mean arterial pressure, cerebral circulation ceases (Porth, 2002). A clinical phenomenon known as the Cushing’s response (or Cushing’s reflex) is seen when cerebral blood flow decreases significantly. When ischemic, the vasomotor center triggers a rise in arterial pressure in an effort to overcome the increased ICP. A sympathetically mediated response causes a rise in the systolic blood pressure with a widening of the pulse pressure and cardiac slowing. This response, which is mediated by the sympathetic nervous system, is seen clinically as a rise in systolic blood pressure, widening of the pulse pressure, and reflex slowing of the heart rate. This is a sign requiring immediate intervention; however, perfusion may be recoverable if treated rapidly. At a certain volume or pressure, the brain’s ability to autoregulate becomes ineffective and decompensation (ischemia and infarction) begins (Young et al., 1998). When this occurs, the patient exhibits significant changes in mental status and vital signs. The bradycardia, hypertension, and bradypnea associated with this deterioration are known as Cushing’s triad, a grave sign. At this point, herniation of the brain stem and occlusion of the cerebral blood flow occur if therapeutic intervention is not initiated. Herniation refers to the shifting of brain tissue from an area of high pressure to an area of lower pressure (Fig. 61-2). The herniated
1
3
FIGURE 61-2
Cross section of normal brain (left) and brain with intracranial shifts from supratentorial lesions (right). (1) Herniation of the cingulated gyrus. (2) Herniation of the temporal lobe into the tentorial notch. (3) Downward displacement of the brainstem through the notch.
2
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NEUROLOGIC FUNCTION
tissue exerts pressure on the brain area to which it has herniated or shifted, interfering with the blood supply in that area. Cessation of cerebral blood flow results in cerebral ischemia and infarction and brain death.
Clinical Manifestations When ICP increases to the point at which the brain’s ability to adjust has reached its limits, neural function is impaired; this may be manifested by clinical changes first in LOC and later by abnormal respiratory and vasomotor responses.
!
NURSING ALERT The earliest sign of increasing ICP is a change in LOC. Slowing of speech and delay in response to verbal suggestions are other early indicators.
Any sudden change in the patient’s condition, such as restlessness (without apparent cause), confusion, or increasing drowsiness, has neurologic significance. These signs may result from compression of the brain due to swelling from hemorrhage or edema, an expanding intracranial lesion (hematoma or tumor), or a combination of both. As ICP increases, the patient becomes stuporous, reacting only to loud auditory or painful stimuli. At this stage, serious impairment of brain circulation is probably taking place, and immediate intervention is required. As neurologic function deteriorates further, the patient becomes comatose and exhibits abnormal motor responses in the form of decortication, decerebration, or flaccidity (see Fig. 61-1). When the coma is profound, with the pupils dilated and fixed and respirations impaired, death is usually inevitable.
Assessment and Diagnostic Findings The diagnostic studies used to determine the underlying cause of increased ICP are discussed in detail in Chapter 60. The patient may undergo cerebral angiography, computed tomography (CT) scanning, magnetic resonance imaging (MRI), or positron emission tomography (PET). Transcranial Doppler studies provide information about cerebral blood flow. The patient with increased ICP may also undergo electrophysiologic monitoring to monitor cerebral blood flow indirectly. Evoked potential monitoring measures the electrical potentials produced by nerve tissue in response to external stimulation (auditory, visual, or sensory). Lumbar puncture is avoided in patients with increased ICP because the sudden release of pressure can cause the brain to herniate.
Complications Complications of increased ICP include brain stem herniation, diabetes insipidus, and syndrome of inappropriate antidiuretic hormone (SIADH). Brain stem herniation results from an excessive increase in ICP, when the pressure builds in the cranial vault and the brain tissue presses down on the brain stem. This increasing pressure on the brain stem results in the cessation of blood flow to the brain, causing irreversible brain anoxia and brain death. Diabetes insipidus is the result of decreased secretion of antidiuretic hormone. The patient has excessive urine output, and hyperosmolarity results (Young et al., 1998). Therapy consists of administration of fluid volume, electrolyte replacement, and vasopressin (desmopressin, DDAVP) therapy. Diabetes insipidus is discussed in Chapters 14 and 42.
SIADH is the result of increased secretion of antidiuretic hormone. The patient becomes volume-overloaded, urine output diminishes, and serum sodium concentration becomes dilute. Treatment of SIADH includes fluid restriction, which is usually sufficient to correct the hyponatremia; severe cases call for judicious administration of a 3% hypertonic saline solution (Hickey, 2003). Patients with chronic SIADH may respond to lithium carbonate or demeclocycline, which reduces renal tubule responsiveness to antidiuretic hormone. Further discussion of SIADH is presented in Chapters 14 and 42.
Management Increased ICP is a true emergency and must be treated promptly. Invasive monitoring of ICP is an important component of management, but immediate management to relieve increased ICP involves decreasing cerebral edema, lowering the volume of CSF, or decreasing cerebral blood volume while maintaining cerebral perfusion (Cunning & Houdek, 1999). These goals are accomplished by administering osmotic diuretics and corticosteroids, restricting fluids, draining CSF, controlling fever, maintaining systemic blood pressure and oxygenation, and reducing cellular metabolic demands. Judicious use of hyperventilation is recommended only if the ICP is refractory to other measures. MONITORING ICP The purposes of ICP monitoring are to identify increased pressure early in its course (before cerebral damage occurs), to quantify the degree of elevation, to initiate appropriate treatment, to provide access to CSF for sampling and drainage, and to evaluate the effectiveness of treatment. An intraventricular catheter (ventriculostomy), a subarachnoid bolt, an epidural or subdural catheter, or a fiberoptic transducer-tipped catheter placed in the subdural space or the ventricle can be used to monitor ICP (Fig. 61-3). When a ventriculostomy or ventricular catheter monitoring device is used for monitoring ICP, a fine-bore catheter is inserted into a lateral ventricle, usually in the nondominant hemisphere of the brain (Hickey, 2003). The catheter is connected by a fluidfilled system to a transducer, which records the pressure in the form of an electrical impulse. In addition to obtaining continuous ICP recordings, the ventricular catheter allows CSF to drain, particularly during acute rises in pressure. The ventriculostomy also can be used to drain the ventricle of blood. Also, continuous drainage of ventricular fluid under pressure control is an effective method of treating intracranial hypertension. Another advantage of an indwelling ventricular catheter is the access it provides for the intraventricular administration of medications and the instillation of air or a contrast agent for ventriculography. Complications include ventricular infection, meningitis, ventricular collapse, occlusion of the catheter by brain tissue or blood, and problems with the monitoring system. The subarachnoid bolt (or screw) is a hollow device inserted through the skull and dura mater into the cranial subarachnoid space (Hickey, 2003). It has the advantage of not requiring a ventricular puncture. The subarachnoid screw is attached to a pressure transducer, and the output is recorded on an oscilloscope. The hollow screw technique has the advantage of avoiding complications from brain shift and small ventricle size. Complications include blockage of the screw by clot or brain tissue, which leads to a loss of pressure tracing and a decrease in accuracy at high ICP readings. An epidural monitor uses a pneumatic flow sensor that functions on a nonelectrical basis. This pneumatic epidural ICP mon-
Chapter 61
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FIGURE 61-3
ICP monitoring. A fiber-optic, transducer-tipped device placed in (A) the ventricle or (B) the subarachnoid space. These devices connect to a pressure transducer and a display system.
itoring system has a low incidence of infection and complications and appears to read pressures accurately. Calibration of the system is maintained automatically, and abnormal pressure waves trigger an alarm system. One disadvantage of the epidural catheter is the inability to withdraw CSF for analysis. A fiberoptic monitor, or transducer-tipped catheter, is becoming a widely used alternative to standard intraventricular, subarachnoid, and subdural systems (Hickey, 2003). The miniature transducer reflects pressure changes, which are converted to electrical signals in an amplifier and displayed on a digital monitor. The catheter can be inserted into the ventricle, subarachnoid space, subdural space, or brain parenchyma or under a bone flap. If inserted into the ventricle, it can also be used in conjunction with a CSF drainage device. Waves of high pressure and troughs of relatively normal pressure indicate changes in ICP. Waveforms are captured and recorded on an oscilloscope. These waves have been classified as A waves (plateau waves), B waves, and C waves (Fig. 61-4). The plateau waves (A waves) are transient, paroxysmal, recurring elevations of ICP that may last 5 to 20 minutes and range in amplitude from 50 to 100 mm Hg (Hickey, 2003). Plateau waves have clinical significance and indicate changes in vascular volume within the intracranial compartment that are beginning to compromise cerebral perfusion. A waves may increase in amplitude and frequency, reflecting cerebral ischemia and brain damage that can occur before overt signs and symptoms of raised ICP are seen clinically. B waves are shorter (30 seconds to 2 minutes), with smaller amplitude (up to 50 mm Hg). They have less clinical significance, but if seen in runs in a patient with depressed consciousness, they may precede the appearance of A waves. B waves may be seen in patients with intracranial hypertension and decreased intracranial compliance. C waves are small, rhythmic oscillations with frequencies of approximately six per minute. They
appear to be related to rhythmic variations of the systemic arterial blood pressure and respirations. DECREASING CEREBRAL EDEMA Osmotic diuretics (mannitol) may be given to dehydrate the brain tissue and reduce cerebral edema. They act by drawing water across intact membranes, thereby reducing the volume of brain and extracellular fluid. An indwelling urinary catheter is usually inserted to monitor urinary output and to manage the resulting diuresis. When a patient is receiving osmotic diuretics, serum osmolality should be determined to assess hydration status. Corticosteroids (eg, dexamethasone) help reduce the edema
FIGURE 61-4
Intracranial pressure waves. Composite diagram of A (plateau) waves, which indicate cerebral ischemia; B waves, which indicate intracranial hypertension and variations in the respiratory cycle; and C waves, which relate to variations in systemic arterial pressure and respirations.
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NEUROLOGIC FUNCTION
surrounding brain tumors when a brain tumor is the cause of increased ICP. Another method for decreasing cerebral edema is fluid restriction (Hickey, 2003). Limiting overall fluid intake leads to dehydration and hemoconcentration, drawing fluid across the osmotic gradient and decreasing cerebral edema. Conversely, overhydration of the patient with increased ICP is avoided, as this will increase cerebral edema. It has been hypothesized that lowering body temperature will decrease cerebral edema, reduce the oxygen and metabolic requirements of the brain, and protect the brain from continued ischemia. If body metabolism can be reduced by lowering body temperature, the collateral circulation in the brain may be able to provide an adequate blood supply to the brain. The effect of hypothermia on ICP requires more study (Slade, Kerr & Marion, 1999), but as yet induced hypothermia has not been proven to be beneficial in the brain-injured patient (Clifton, Miller, Choi et al., 2001). Inducing and maintaining hypothermia is a major clinical procedure and requires knowledge and skilled nursing observation and management. MAINTAINING CEREBRAL PERFUSION The cardiac output may be manipulated to provide adequate perfusion to the brain. Improvements in cardiac output are made using fluid volume and inotropic agents such as dobutamine hydrochloride. The effectiveness of the cardiac output is reflected in the cerebral perfusion pressure, which is maintained at greater than 70 mm Hg (Young et al., 1998). A lower cerebral perfusion pressure indicates that the cardiac output is insufficient to maintain adequate cerebral perfusion. REDUCING CSF AND INTRACRANIAL BLOOD VOLUME CSF drainage is frequently performed because the removal of CSF with a ventriculostomy drain may dramatically reduce ICP and restore cerebral perfusion pressure. Caution should be used in draining CSF because excessive drainage may result in collapse of the ventricles. Hyperventilation, which results in vasoconstriction, has been used for many years in patients with increased ICP. Recent research has demonstrated that hyperventilation may not be as beneficial as once thought (Hickey, 2003). The reduction in the PaCO2 may result in hypoxia, ischemia, and an increase in cerebral lactate levels. Maintaining the PaCO2 at 30 to 35 mm Hg may prove beneficial. Hyperventilation is indicated in patients whose ICP is unresponsive to conventional therapies, but it should be used judiciously. CONTROLLING FEVER Preventing a temperature elevation is critical because fever increases cerebral metabolism and the rate at which cerebral edema forms. Strategies to reduce temperature include administration of antipyretic medications, as prescribed, and use of a cooling blanket. Additional strategies for reducing fever are included in the Nursing Process: The Patient With an Altered Level of Consciousness section of this chapter. The patient’s temperature is monitored closely, and the patient is observed for shivering, which should be avoided because it increases ICP (Sund-Levander & Wahren, 2000). MAINTAINING OXYGENATION Arterial blood gases must be monitored to ensure that systemic oxygenation remains optimal. Hemoglobin saturation can also be optimized to provide oxygen more efficiently at the cellular level.
REDUCING METABOLIC DEMANDS Cellular metabolic demands may be reduced through the administration of high doses of barbiturates when the patient is unresponsive to conventional treatment. The mechanism by which barbiturates decrease ICP and protect the brain is uncertain, but the resultant comatose state is thought to reduce the metabolic requirements of the brain, thus providing some protection (Greenberg, 2001). Another method of reducing cellular metabolic demand and improving oxygenation is the administration of pharmacologic paralyzing agents. The patient who receives these agents cannot move, decreasing the metabolic demands and resulting in a decrease in cerebral oxygen demand. Because the patient cannot respond or report pain, sedation and analgesia must be provided because the paralyzing agents do not provide either. Patients receiving high doses of barbiturates or pharmacologic paralyzing agents require continuous cardiac monitoring, endotracheal intubation, mechanical ventilation, ICP monitoring, and arterial pressure monitoring. Pentobarbital (Nembutal), thiopental (Pentothal), and propofol (Diprivan) are the most common agents used for high-dose barbiturate therapy (Greenberg, 2001). Serum barbiturate levels must be monitored (Hickey, 2003). The ability to perform serial neurologic assessments on the patient is lost with the use of barbiturates or paralyzing agents (Greenberg, 2001). Therefore, other monitoring tools are needed to assess the patient’s status and response to therapy. Important parameters that must be assessed include ICP, blood pressure, heart rate, respiratory rate, and response to ventilator therapy (eg, bucking the ventilator). The level of pharmacologic paralysis is adjusted based on serum levels and the assessed parameters. Potential complications include hypotension due to decreased sympathetic tone and myocardial depression (Greenberg, 2001). TRENDS IN NEUROLOGIC MONITORING One controversial trend in cerebral monitoring is the ongoing measurement of venous oxygen saturation in the jugular bulb (SjO2). Readings taken from a catheter residing in the jugular outflow tract theoretically allow for a comparison of arterial and venous oxygen saturation, and the balance of cerebral oxygen supply and demand is demonstrated. Venous jugular desaturations can reflect early cerebral ischemia, alerting the clinician prior to a rise in ICP. Minimizing elevations in ICP can potentially improve outcome (Clay, 2000). This type of monitoring appears beneficial in the management of patients at risk for cerebral ischemia; however, the invasive nature of this type of monitoring and current limitations in technology mandate caution in its use. More study is needed before SjO2 monitoring can be considered a valid and reliable tool for the management of cerebral ischemia (Clay, 2000).
NURSING PROCESS: THE PATIENT WITH INCREASED ICP Assessment Initial assessment of the patient with increased ICP includes obtaining a history of events leading to the present illness and other subjective data; it may be necessary to obtain this information from family or friends. The neurologic examination should be as complete as the patient’s condition allows. It includes an evaluation of mental status, LOC, cranial nerve function, cerebellar function (balance and coordination), reflexes, and motor and sensory function. Because the patient is critically ill, ongoing assessment will
Chapter 61 be more focused, including pupil checks, assessment of selected cranial nerves, frequent measurements of vital signs and intracranial pressure, and use of the Glasgow Coma Scale. Assessment of the patient with altered LOC is summarized in Table 61-1.
Diagnosis NURSING DIAGNOSES Based on the assessment data, the major nursing diagnoses for patients with increased ICP include the following:
• Ineffective airway clearance related to diminished protective reflexes (cough, gag)
• Ineffective breathing patterns related to neurologic dys-
function (brain stem compression, structural displacement)
• Ineffective cerebral tissue perfusion related to the effects of increased ICP
• Deficient fluid volume related to fluid restriction • Risk for infection related to ICP monitoring system (fiberoptic or intraventricular catheter)
Other relevant nursing diagnoses are included in the section on caring for patients with altered LOC. COLLABORATIVE PROBLEMS/ POTENTIAL COMPLICATIONS Based on the assessment data, potential complications include:
• Brain stem herniation • Diabetes insipidus • SIADH Planning and Goals The goals for the patient include maintenance of a patent airway, normalization of respiration, adequate cerebral tissue perfusion through reduction in ICP, restoration of fluid balance, absence of infection, and absence of complications.
Nursing Interventions MAINTAINING A PATENT AIRWAY The patency of the airway is assessed. Secretions obstructing the airway must be suctioned with care, because transient elevations of ICP occur with suctioning (Hickey, 2003). The patient is hyperoxygenated before and after suctioning to maintain adequate oxygenation. Hypoxia caused by poor oxygenation leads to cerebral ischemia and edema. Coughing is discouraged because coughing and straining also increase ICP. The lung fields are auscultated at least every 8 hours to determine the presence of adventitious sounds or any areas of congestion. Elevating the head of the bed may aid in clearing secretions as well as improving venous drainage of the brain. ACHIEVING AN ADEQUATE BREATHING PATTERN The patient must be monitored constantly for respiratory irregularities. Increased pressure on the frontal lobes or deep midline structures may result in Cheyne-Stokes respirations, whereas pressure in the midbrain may cause hyperventilation. When the lower portion of the brain stem (the pons and medulla) is involved, respirations become irregular and eventually cease. If hyperventilation therapy is deemed appropriate to reduce ICP (by causing cerebral vasoconstriction and a decrease in cerebral blood volume), the nurse collaborates with the respiratory
Management of Patients With Neurologic Dysfunction
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therapist in monitoring PaCO2, which is usually maintained at 35 to 45 mm Hg (Hickey, 2003). A neurologic observation record (Fig. 61-5) is maintained, and all observations are made in relation to the patient’s baseline condition. Repeated assessments of the patient are made (sometimes minute by minute) so that improvement or deterioration may be noted immediately. If the patient’s condition deteriorates, preparations are made for surgical intervention. OPTIMIZING CEREBRAL TISSUE PERFUSION In addition to ongoing nursing assessment, strategies are initiated to reduce factors contributing to the elevation of ICP (Table 61-2). Proper positioning helps to reduce ICP. The head is kept in a neutral (midline) position, maintained with the use of a cervical collar if necessary, to promote venous drainage. Elevation of the head is maintained at 0 to 60 degrees to aid in venous drainage unless otherwise prescribed (Sullivan, 2000). Extreme rotation of the neck and flexion of the neck are avoided because compression or distortion of the jugular veins increases ICP. Extreme hip flexion is also avoided because this position causes an increase in intra-abdominal and intrathoracic pressures, which can produce a rise in ICP. Relatively minor changes in position may significantly affect ICP (Sullivan, 2000). If monitoring parameters demonstrate that turning the patient raises ICP, rotating beds, turning sheets, and holding the patient’s head during turning may minimize the stimuli that increase ICP. The Valsalva maneuver, which can be produced by straining at defecation or even moving in bed, raises ICP and is to be avoided. Stool softeners may be prescribed. If the patient is alert and able to eat, a diet high in fiber may be indicated. Abdominal distention, which increases intra-abdominal and intrathoracic pressure and ICP, should be noted. Enemas and cathartics are avoided if possible. When moving or being turned in bed, the patient can be instructed to exhale (which opens the glottis) to avoid the Valsalva maneuver. Mechanical ventilation presents unique problems for the patient with increased ICP. Before suctioning, the patient should be preoxygenated and hyperventilated using 100% oxygen on the ventilator (Hickey, 2003). Suctioning should not last longer than 15 seconds. High levels of positive end-expiratory pressure are avoided because they may decrease venous return to the heart and decrease venous drainage from the brain through increased intrathoracic pressure (Hickey, 2003). Activities that raise ICP, as indicated by changes in waveforms, should be avoided if possible. Spacing nursing interventions may prevent transient increases in ICP. During nursing interventions, the ICP should not rise above 25 mm Hg and should return to baseline levels within 5 minutes. Patients with increased ICP should not demonstrate a significant increase in pressure or change in the ICP waveform. Patients with the potential for a significant increase in ICP should receive sedation or “paralyzation” before initiation of many nursing activities (Hickey, 2003; McConnell, 2001). Emotional stress and frequent arousal from sleep are avoided. A calm atmosphere is maintained. Environmental stimuli (noise, conversation) should be minimal. Isometric muscle contractions are also contraindicated because they raise the systemic blood pressure and hence the ICP. MAINTAINING NEGATIVE FLUID BALANCE The administration of various osmotic and loop diuretics is part of the treatment protocol to reduce ICP. Corticosteroids are used (text continues on page 1864)
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NURSING NEUROLOGICAL CRITICAL CARE FLOWSHEET
ADDRESSOGRAPH Date Time Initials
Person Level of orientation (✓)
Place Date and time No orientation Voice Touch
Awakens to (✓)
Noxious stimuli Painful stimuli No response Clear and appropriate Clear and inappropriate Difficulty speaking*
Best verbal response (✓)
Perseveration Aphasic expressive (non-fluent) Aphasic receptive (fluent) Sounds no speech No response ETT/TRACH Moves all extremities purposefully Withdraws and lifts to painful stimuli
Best motor response (✓)
Moves to painful stimuli Triple flexes (spinal reflex) Decorticates (spinal reflex) Decerebrates (spinal reflex) No response
Best motor strength upper extremities (✓)
Best strength lower extremities (✓) Seizure activity (✓)
No drifts (R/L)
R
Drift (R/L)
R
Can only lift forearm (R/L)
R
Trace movement of hand or arm (R/L)
R
Trace movement of fingers only (R/L)
R
No response (R/L)
R
Raises leg off bed (R/L)
R
Drags heel on bed and lifts knee (R/L)
R
Trace movement of foot or leg (R/L)
R
Trace movement of toes only (R/L)
R
No response (R/L)
R
L L L L L L L L L L L
R R R R R R R R R R R
L L L L L L L L L L L
R R R R R R R R R R R
L L L L L L L L L L L
R R R R R R R R R R R
No seizure activity With loss of consciousness* Without loss of consciousness* Gross ataxia
Ataxia (✓)
Fine motor ataxia Does not apply Ventriculostomy MLS
ICP monitoring
ICP mm Hg Not applicable
*= FURTHER DOCUMENTATION IS REQUIRED TO VALIDATE ASSESSMENT
FIGURE 61-5
A neurological assessment flow sheet.
L L L L L L L L L L L
R R R R R R R R R R R
L L L L L L L L L L L
R R R R R R R R R R R
L L L L L L L L L L L
R R R R R R R R R R R
L L L L L L L L L L L
R R R R R R R R R R R
L L L L L L L L L L L
R R R R R R R R R R R
L L L L L L L L L L L
R R R R R R R R R R R
L L L L L L L L L L L
R R R R R R R R R R R
L L L L L L L L L L L
R R R R R R R R R R R
L L L L L L L L L L L
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PUPIL GAUGE (mm)
2
3
4
5
6 ADDRESSOGRAPH Date
7
8
9
B=Brisk, S=Sluggish, F=Fixed Incision +/–
Pupils refer to gauge (✓) (+)=Present (–)=Absent Meningeal signs (+)=Present (–)=Absent
Time Initials
Dry and intact Drainage Size (R/L)
R
Regular (R/L)
R
Irregular* (R/L)
R
Reaction (R/L) (B) - (S) - (F)
R
Ptosis (R/L) (+) (–)
R
Gaze preference (R/L) (+)* (–)
R
R
R
L
L
L
L
L
L
L
L
L
L
L
L
L
L
L R
R
R
R
R
R
R
R
R
R
R
R
L
L
L
L
L
L
L
L R
R
R
R
R
R
R L
L
L
L
R
R
R
R L
R L
L
L
L
L
L
R
R
R
R L
L
L
L
R
R
R
R L
L
L R
R L
R
R L
L
L
L
L
R
R
R
R L
L
L
L
L
L
L
L
R
R
R
R L
L
L
L
L
L
L
L R
R
R
R
R
R
R
R
R
R
R
R L
L
L
L
R
R
R
R L
L
L
L
R
R
R
R L
Headache Nuchal rigidity Photophobia
Right upper outer Visual fields (+)=Present Right lower outer (–)=Absent* Left upper outer NA=Not applicable
Nystagmus (+)=Present (–)=Absent
Left lower outer Lateral (R/L)
R
Vertical (R/L)
R
R L
R L
L
L
L
L
L
L
L
L
R
R
R
R
R
R
R
R
R L
L
L
L
R
R
R
R L
L
L
L
R
R
R
R L
R L
R L
L R
L
L
III, IV, VI, Extra occular movements
Cranial nerves (+)=Present (–)=Absent
VII – Peripheral facial droop (R/L)
R
XII – Tongue deviation (R/L)
R
R L
R L
L
L
L
L
L
L
L
L
R
R
R
R
R
R
R
R
R L
L
L
L
R
R
R
R L
L
L
L
R
R
R
R L
R L
R L
L R
L
L
IX – Gag reflex V, VII – Corneal reflex (R/L)
R
R L
R L
R L
R L
R L
R L
R L
R L
R L
R L
R L
X, IX – Cough reflex Doll's eyes if appropriate Two step verbal command Follows commands
One step verbal command Unable to follow command
*= FURTHER DOCUMENTATION IS REQUIRED TO VALIDATE ASSESSMENT Initials
Signature
Title
Initials
Signature
Title
L
Unit 14
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Table 61-2
NEUROLOGIC FUNCTION
• Increased ICP and Interventions
FACTOR
PHYSIOLOGY
INTERVENTIONS
RATIONALE
Cerebral edema
Can be caused by contusion, tumor, or abscess; water intoxication (hypoosmolality); alteration in the blood– brain barrier (protein leaks into the tissue, causing water to follow) A decrease in the PaO2 causes cerebral vasodilation at less than 60 mm Hg.
Administer osmotic diuretics as prescribed (monitor serum osmolality). Maintain head of bed elevated 30 degrees. Maintain alignment of the head. Maintain PaO2 greater than 60 mm Hg. Maintain oxygen therapy. Monitor arterial blood gas values. Suction when needed. Maintain a patent airway. Maintain PaCO2 (normally 35–45 mm Hg) through hyperventilation. Maintain head alignment. Elevate head of bed 30 degrees.
Promotes venous return
Hypoxia
Hypercapnia (elevated PaCO2)
Causes vasodilation
Impaired venous return
Increases the cerebral blood volume
Increase in intrathoracic or abdominal pressure
Increase in these pressures due to coughing, PEEP, Valsalva maneuver causes a decrease in venous return.
Monitor arterial blood gas values and keep PEEP as low as possible. Provide humidified oxygen. Administer stool softeners as prescribed.
to reduce cerebral edema, and fluids may be restricted. All of these treatment modalities promote dehydration. Skin turgor, mucous membranes, and serum and urine osmolality are monitored to assess fluid status. If fluids are given intravenously, the nurse ensures they are administered at a slow to moderate rate with an intravenous infusion pump to prevent too-rapid administration and avoid overhydration. For the patient receiving mannitol, the nurse observes for the possible development of heart failure and pulmonary edema, because the intent of treatment is for fluid to shift from the intracellular compartment to the intravascular system, thus controlling cerebral edema. For patients undergoing dehydrating procedures, vital signs, including blood pressure, must be monitored to assess fluid volume status. An indwelling urinary catheter is inserted to permit assessment of renal function and fluid status. During the acute phase, urine output should be monitored every hour. An output greater than 200 mL/hr for 2 consecutive hours may indicate the onset of diabetes insipidus (Cruz, 1998). These patients also need careful oral hygiene because mouth dryness is associated with dehydration. Frequently rinsing the mouth, lubricating the lips, and removing encrustations relieve dryness and promote comfort. PREVENTING INFECTION Risk for infection is greatest when ICP is monitored with an intraventricular catheter. Most health care facilities have written protocols for managing these systems and maintaining their sterility; strict adherence to them is essential. The dressing over the ventricular catheter must be kept dry because a wet dressing is conducive to bacterial growth. Aseptic technique must be used when managing the system and changing the ventricular drainage bag. The drainage system is also checked
Prevents impairment of venous return through the jugular veins Prevents hypoxia and vasodilation
Decreased PaCO2 prevents vasodilation and thus reduces the cerebral blood volume. Hyperextension, rotation, or hyperflexion of the neck causes decreased venous return. To keep secretions loose and easy to suction or expectorate Soft bowel movements will prevent straining or Valsalva maneuver.
for loose connections because they cause leakage and contamination of the CSF as well as inaccurate readings of ICP. The nurse should observe the character of the CSF drainage and report observations of increasing cloudiness or blood. The patient is monitored for signs and symptoms of meningitis: fever, chills, nuchal (neck) rigidity, and increasing or persisting headache. MONITORING AND MANAGING POTENTIAL COMPLICATIONS The primary complication of increased ICP is brain herniation resulting in death (see Fig. 61-2). Nursing management focuses on detecting early signs of increasing ICP because medical interventions are usually ineffective once later signs develop. Frequent neurologic assessment and documentation and analysis of trends will reveal the subtle changes that may herald rising ICP. Detecting Early Indications of Increasing ICP The nurse assesses for and immediately reports any of the following early signs or symptoms of increasing ICP:
• Disorientation, restlessness, increased respiratory effort, pur-
•
•
poseless movements, and mental confusion; these are early clinical indications of rising ICP because the brain cells responsible for cognition are extremely sensitive to decreased oxygenation Pupillary changes and impaired extraocular movements; these occur as the increasing pressure displaces the brain against the oculomotor and optic nerves (cranial nerves II, III, IV, and VI) arising from the midbrain and brain stem (see Chap. 60) Weakness in one extremity or on one side of the body; this occurs as increasing ICP compresses the pyramidal tracts
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• Headache that is constant, increasing in intensity, and aggravated by movement or straining; this occurs as increasing ICP causes pressure and stretching of venous and arterial vessels in the base of the brain Detecting Later Signs of Increased ICP As ICP rises, the patient’s condition worsens, as manifested by the following later signs and symptoms:
• LOC continues to deteriorate until the patient is comatose. • The pulse rate and respiratory rate decrease or become er-
•
• • •
ratic, and the blood pressure and temperature rise. The pulse pressure (the difference between the systolic and the diastolic pressures) widens. The pulse fluctuates rapidly, varying from bradycardia to tachycardia. Altered respiratory patterns develop, including CheyneStokes breathing (rhythmic waxing and waning of rate and depth of respirations alternating with brief periods of apnea) and ataxic breathing (irregular breathing with a random sequence of deep and shallow breaths). Projectile vomiting may occur with increased pressure on the reflex center in the medulla. Hemiplegia or decorticate or decerebrate posturing may develop as pressure on the brain stem increases. Bilateral flaccidity occurs before death. Loss of brain stem reflexes, including pupillary, corneal, gag, and swallowing reflexes, is an ominous sign.
Monitoring ICP Because clinical assessment is not always a reliable guide in recognizing increased ICP, especially in comatose patients, ICP monitoring is an essential part of management (Hickey, 2003). ICP is monitored closely for continuous elevation or significant increase over baseline. The trend of ICP measurements over time is an important indication of the patient’s underlying status. Vital signs are assessed when the increase in ICP is noted. Strict aseptic technique is used when handling any part of the monitoring system. The insertion site is inspected for signs of infection. Temperature, pulse, and respirations are closely monitored for systemic signs of infection. All connections and stopcocks are checked for leaks, because even small leaks can distort pressure readings. When ICP is monitored with a fluid system, the transducer is calibrated at a particular reference point, usually 2.5 cm (1 in) above the ear with the patient in the supine position; this point corresponds to the level of the foramen of Monro (Fig. 61-6). (CSF pressure readings depend on the patient’s position.) For subsequent pressure readings, the head should be in the same position relative to the transducer. Fiberoptic catheters are calibrated before insertion and do not require further referencing; they do not require the head of the bed to be at a specific position to obtain an accurate reading. Whenever technology is associated with patient management, the nurse must be certain that the technology is functioning properly. The most important concern, however, must be the patient who is attached to the technology. The patient and family must be informed about the technology and the goals of its use. The patient’s response is monitored and appropriate comfort measures are implemented to ensure that the patient’s stress is minimized. ICP measurement is only one parameter: repeated neurologic checks and clinical examinations remain important measures. As-
FIGURE 61-6
Location of the foramen of Monro for calibration of intracranial pressure monitoring system.
tute observation, comparison of findings with previous observations, and interventions can assist in preventing life-threatening ICP elevations. Monitoring for Secondary Complications The nurse also assesses for complications of increased ICP, including diabetes insipidus and SIADH (see Chaps. 14 and 42). Urine output should be monitored closely. Diabetes insipidus requires fluid and electrolyte replacement, along with the administration of vasopressin, to replace and slow the urine output. Serum electrolyte levels should be monitored for imbalances. SIADH requires fluid restriction and monitoring of serum electrolyte levels.
Evaluation EXPECTED PATIENT OUTCOMES Expected patient outcomes may include: 1. Maintains patent airway 2. Attains optimal breathing pattern a. Breathes in a regular pattern b. Attains or maintains arterial blood gas values within acceptable range 3. Demonstrates optimal cerebral tissue perfusion a. Increasingly oriented to time, place, and person b. Follows verbal commands; answers questions correctly 4. Attains desired fluid balance a. Maintains fluid restriction b. Demonstrates serum and urine osmolality values within acceptable range 5. Has no signs or symptoms of infection a. Has no fever b. Shows no signs of infection at arterial, intravenous, and urinary catheter sites c. Has no purulent drainage from invasive intracranial monitoring device
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NEUROLOGIC FUNCTION
6. Absence of complications a. Has ICP values that remain within normal limits b. Demonstrates urine output and serum electrolyte levels within acceptable limits
Intracranial Surgery A craniotomy involves opening the skull surgically to gain access to intracranial structures. This procedure is performed to remove a tumor, relieve elevated ICP, evacuate a blood clot, and control hemorrhage. The surgeon cuts the skull to create a bony flap, which can be repositioned after surgery and held in place by periosteal or wire sutures. One of two approaches through the skull is used: (1) above the tentorium (supratentorial craniotomy) into the supratentorial compartment, or (2) below the tentorium into the infratentorial (posterior fossa) compartment. A transsphenoidal approach through the mouth and nasal sinuses is used to gain access to the pituitary gland. Table 61-3 compares the three different surgical approaches: supratentorial, infratentorial, and transsphenoidal. Alternatively, intracranial structures may be approached through burr holes (Fig. 61-7), which are circular openings made in the skull by either a hand drill or an automatic craniotome
Table 61-3
(which has a self-controlled system to stop the drill when the bone is penetrated). Burr holes are made for exploration or diagnosis. They may be used to determine the presence of cerebral swelling and injury and the size and position of the ventricles. They are also a means of evacuating an intracranial hematoma or abscess and for making a bone flap in the skull and allowing access to the ventricles for decompression, ventriculography, or shunting procedures. Other cranial procedures include craniectomy (excision of a portion of the skull) and cranioplasty (repair of a cranial defect using a plastic or metal plate).
Preoperative Management Preoperative diagnostic procedures may include CT scanning to demonstrate the lesion and show the degree of surrounding brain edema, the ventricular size, and the displacement. MRI provides information similar to that of the CT scan and examines the lesion in other planes (Tornqvist, 2001). Cerebral angiography may be used to study the tumor’s blood supply or give information about vascular lesions. Transcranial Doppler flow studies are used to evaluate the blood flow of intracranial blood vessels. Most patients are placed on an antiseizure medication such as phenytoin (Dilantin) or a phenytoin metabolite (Cerebyx) before surgery to reduce the risk of postoperative seizures (paroxysmal
• Comparison of Cranial Surgical Approaches
SUPRATENTORIAL
Site of Surgery Above the tentorium Incision Location Incision is made above the area to be operated on; is usually located behind the hairline. Selected Nursing Interventions Maintain head of bed elevated 30 to 45 degrees, with neck in neural alignment. Position patient on either side or back. (Avoid positioning patient on operative side if a large tumor has been removed.)
INFRATENTORIAL
TRANSSPHENOIDAL
Below the tentorium, brain stem
Sella turcica
Incision is made at the nape of the neck, around the occipital lobe.
Incision is made beneath the upper lip to gain access into the nasal cavity.
Maintain neck in straight alignment. Avoid flexion of the neck to prevent possible tearing of the suture line. Position the patient on either side. (Check surgeon’s preference for positioning of patient.)
Maintain nasal packing in place and reinforce as needed. Instruct patient to avoid blowing the nose. Provide frequent oral care. Keep head of bed elevated to promote venous drainage and drainage from the surgical site.
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water, blanket, and other frequently used items may help improve communication. Preparation of the patient and family includes providing information about what to expect during and after surgery. The surgical site is shaved immediately before surgery (usually in the operating room) so that any resultant superficial abrasions do not have time to become infected. An indwelling urinary catheter is inserted in the operating room to drain the bladder during the administration of diuretics and to permit urinary output to be monitored. The patient may have a central and arterial line placed for fluid administration and monitoring of pressures after surgery. The large head dressing appl
