RESEARCH ON ACUTE BIOLOGIC CRISIS

Presented to

ROSELYN S. PACARDO, MAN, MM, RN, RM

MINDANAO SANITARIUM AND HOSPITAL COLLEGE Barangay San Miguel, Iligan City

In Partial Fulfillment of the Requirements for the Degree BACHELOR OF SCIENCE IN NURSING

Keff Jester T. Munda

JUNE 2011
SEXUALLY TRANSMITTED DISEASES

SEXUALLY TRANSMITTED DISEASE Candidiasis

RISK FACTORS - pregnancy due to high estrogen levels that leads to increased glycogen levels - people who
have a weakened immune system because of cancer treatments

CAUSATIVE AGENT candida albicans

INCUBATION PERIOD 2 to 5 days

MODE OF TRANSMISSIO N Sexual intercourse

SIGNS AND SYMPTOMS - In women,

signs and symptoms of a vaginal yeast infection are a white discharge that is thick and often described as having a cottage cheese appearance.

DIAGNOSTIC TESTS - Microscopic examination (a sample of discharge is taken from the vaginal wall and placing it on a glass slide; three or four drops of a 20% potassium hydroxide (KOH) solution are then added, and then mixture is protected by a cover slip. Typical hyphae under a microscopic exam indicates Candida organisms. - Culturing

DRUGS -Nystatine or miconazole (Monistat) suppositories once a day for 3 to 7 days - Fluconazole (Diflucan) taken orally (onge time or single dose) Classification: Anti-fungal agent Action: Increases fungal cell wall permeability, thereby exerting fungicidal or fungostatic action. Pregnancy Risk Category: C Dosage: 150 mg orally as a single dose

NURSING INTERVENTIONS AND HEALTH EDUCATION - Instruct the adolescent that this drug is given as onetime single dose. - Teach the client about safer sex measures and hygiene practices to help prevent reinfection after therapy. - Urge adolescent to watch for signs and symptoms of possible re-infection and report them to the primary caregiver. - Bathing with dilute sodium bicarbonate solution to relive pruritus.

-Use of devices
implanted in the skin such as urinary catheters and IV ports

- vulvar reddening and pruritus - pain on coitus or on tampon insertion - may be present at other body sites such as the oral cavity or a moist area such as the umbilicus

- woman having antibiotic therapy that would alter the vaginal flora; e.g. tetracyclines - use of oral contraceptives - diabetes milletus - unsafe sex

Trichomoniasis

having multiple sex partners - having a partner who has had multiple sex partners - engaging in unprotected sexual activity - having gonorrhea or nongonococcal urethritis (NGU)
-

ProtozoanTricomonas vaginalis, a
flagellated motile protozoan.

4 to 20 days, with average being 7 days.

Usually passed by direct sexual contact. Can be transmitted through contact with wet objects, such as towels, wash clothes and douching equipment.

Women Vaginal itching Smelly, itchy, and typically frothy or foamydischarge Yellow or graygreen discharge, Pain with urination possible Up to one-third of infected women have no symptoms Men The majority of infected men have no symptoms Urethral

- Microscopic examination of some amount of vaginal discharge combined with lactated Ringers solution or normal saline solution; trichomoniasis typically appear as rounded, mobile structures.

Possible Adverse Effects: Nausea, vomiting, diarrhea, abdominal pain, headache -The treatment of
choice is antibioticsprescr ibed by the doctor.

- Treatment with flagyl and use of condom by sexual partner - Dont drink alcohol in the course of treatment which can cause nausea and vomiting - Patient should avoid sex until drug therapy is completed and all symptoms have disappeared. Treatment of the patients partner is crucial to avoid reinfection. - Encouraged patient to verbalize feelings of anxiety - Assure patient that taking or following the treatment regimen reduces the microorganism

- Oral metronidazole (Flagyl) pregnancy test must be take first before taking this medication; tetratogenic

discharge Pain with urination Pain and swelling in the scrotum (fro m epididymitis)

- Instruct patient on how to do proper perineal care - Encourage patient not to engage in sexual activities - Provide a restful environment for the patient
- Speculum examination - Pelvic exam - Whiff test (amine test) - Wet film (drop of vaginal secretion and drop of saline) - Gram stain - Microscopic exam of specimen with normal saline showing gramnegative rods that adhere to the vaginal epithelial cells termed as clue - Metronidazole (500 mg twice a day, 12 hourly) for 7 days - vaginal clindamycin cream (Cleocin) - Teach patient to avoid douching - Instruct the patient not to wear tight fitted under wear - Avoid foods that may aggravate the problem such as coffee, beer, mushrooms, breads, sugary foods - Include yogurt in the diet - Teach patient to replace your fancy underwear with cotton panties

Bacterial Vaginosis

- Sexually active individual - increase vaginal PH - decrease lactobacilli - change of sexual partner -recent antibiotic
use - vaginal douching, and cigarette smoking

Gardnerella Vaginalis

3-7 days for initial infection

Sexual intercourse

- milky gray discharge, fishlike odor - itchiness - edema and reddening of vulva

cells

Chlamydia

- age younger than 20 years old - unmarried - nulliparity - multiple sexual partners or a new sexual partner - use of nonbarrier method of birth control - concurrent gonorrhea

Chlamydia Trachomatis, an intracellular bacteria

1 to 5 weeks

- invades the epithelial tissues in the reproductive tract - sexual intercourse - infection in a mother can cause eye infection or pneumonia in the newborn

- Men: urethritis, frequent urination, and a mucoid discharge that is more watery and less copious; some men may have discharge in the morning upon arising. - Women: may have no symptoms; if woman have symptoms, they have mucopurulent cervicitis with a change in vaginal discharge which is yellow and opaque, easily induced cervical bleeding, urinary frequency, and

- Culture of the organism - Gram Staining - Gene amplification of DNA amplification test - Enzymelinked immunoassay (ELISA) - Direct fluorescent antibody (DFA) - Urinalysis

-Treatment of Choice: azithromycin (Zithromax) 1 gram in a single dose - Oral tetracycline or doxycycline 100 mg twice daily for 7 days - During pregnancy: treated with erythromycin because tetracycline is tetratogenic.

- Client education by explaining the following: The mode of disease transmission The incubation period Manifestations including the possibility of asymptomatic infections Treatment of infection with antibiotics The need for abstinence from sexual intercourse until the client and partners have completed treatment No test of cure is required, but all women should be re-screened 3 to 4 months after treatment because of the high risk for PID if re-infection

abdominal discomfort or pain.

Syphilis

unprotected sex, - sex with multiple partners, having sex with a new partner, or having sex under the influence of drugs or alcohol - Are a man who has sex with men - Are infected
-

Spirochete Treponema pallidum with a slender spiral shape that resembles a corkscrew.

10 to 90 days

- sexual contact - oral-genital - genital-anal contact - close body contact and kissing

Primary syphilis: - Appearance of chancre that develops at the site of entry; may be found on any area of the skin or mucous membranes but occur most often on the genitalia, lips, nipples, and hands, and in the oral cavity,

- Specimen exam under a dark field microscope - Blood test (Venereal Disease Research Lab) serum test; becomes reactive 2 to 6 weeks after infections - Treponemal tests

occurs. The need to return for evaluation if symptoms recur or new symptoms develop (most recurrence are actually reinfections from a new or untreated partner). Possible complications of untreated or inadequately treated infections, such as PID, ectopic pregnancy, or infertility. - Antibiotics the Health Promotion/ drug of choice is Prevention: benzathine penicillin G; Health education the single does of most important aspect 2.4 million unit for prevention that dose includes safer sex practices: - use latex condom for genital and anal intercourse - use a condom or latex barrier (dental dam) over the genitals or anus during oralgenital or oral-anal

with the human immunodeficie ncy virus (HIV)

anus, and rectum. - The chancre begins as a small papule; within 3 to 7 days it breaks down into its typical appearance; a painless, indurated, smooth weeping lesions. - Regional lymph nodes enlarge, feel firm, and are not painful. - Without treatment, the chancre disappears within 6 weeks but the microorganism spread throughout the body and the client is still infectious. Secondary Syphilis: - Develops 6

sexual contact -use latex gloves for finger of hand contact with the vagina or rectum - abstinence and decreasing the number of sexual partners - avoid douching; it can damage or change the natural flora of the vagina Nursing Interventions: - Skin test for sensitive clients - Penicillin desensitization for penicillin-allergic clients - Monitor for allergic reactions - Stay for at least 30 minutes after receiving injection - Check for JarishHerxheimer reaction caused by the rapid release of products from the disruption of the cells of the organism; onset: 2 hours after therapy; peak: 4 to 8 hours; signs and symptoms:

weeks to 6 months - Systemic disease - Malaise, lowgrade fever, headache, muscular aches and pains, sore throat, generalized copper-colored rash of palms and soles (papules to squamous papules to pustules), psoriasis-like rashes, wartlike lesions (condyloma lata), and mucous patches. - Lesions are highly contagious and should not be touched without gloves - Subsided in 4 to 12 weeks without treatment

generalized aches, pain at the injection site, vasodilation, and hypotension, and a rise in temperature; symptoms may not often occur and benign

Early and Latent Sypilis: - Early latent syphilis occurs after the first year; infectious lesions can recur. - Late latent syphilis a disease more than 1 years duration after infection; not infections except to the fetus; may or may not have reactive serologic test findings. Tertiary/Late Syphilis: - Occurs after a highly variable period from 4 to 20 years - Benign lesions (gummas) of the skin, mucous membranes,

and bones Cardiovascular syphilis: aortic valvular disease, aortic aneurysms Neurosyphilis: CNS problems (meningitis, hearing loss, blindness, generalized paresis, paralysis, mental confusion, lack of coordination). Males: chancre on the penis or scrotum Female: inguinal lymph nodes enlargement, chancre in the vagina, or cervix, rashes
Herpes Simplex Virus Type 2 - person with infected sores - immuno Herpes virus hominis (HVH)

2 to 20 days (average 1 week)

- transmitted by sexual contact - close contact

- slight fever to a group of blisters - itching, burning

- specific virus culture or assay for herpes virus

- acyclovir (Zovirax) - famciclovir (Famvir)

- instruct the infected patient to keep the infected area as clean and dry as possible

suppress person - Stress - Vigorous sex - Poor diet - Monthly period

with an infected person who is shedding virus from the skin, often in saliva or in secretions from the genitals

in the genital area - discomfort urinating - watery vaginal or urethral discharge - Blister-like sores appear on or near the sex organs - Swollen glands - Fever - Headache - Muscle aches

- Cell Culture Test - Antigen test - Pap Smear - blood tests

- valacyclovir (Valtrex)

- instruct the patient to have a warm shower in order to cleanse the infected area - teach the patient to avoid tight-fitting underwears - creams and lotions do no good and may even irritate. - need for proper nutrition, exercise, and rest. - Teach patient about the importance of strong immune system to help fight against infection

Gonorrhea

Younger age A new sex partner - Multiple sex partners - Previous gonorrhea diagnosis
-

Bacteria: Neisseria gonorrheae.

Usually 2-10 days, possibly 3 days or more

Typically passed by direct contact between the infectious mucous membranes, e.g. genitals, anus, and mouth of one person with the mucous membranes of another. Contaminated fingers can pass the organism from infected mucous membranes to

Genitals (penis or cervix), anus, throat and eyes can be infected. Males: - Burning urination and pus discharges from infection of urethra (510% have no symptoms) Females:

- Gram staining - Culture of cervical & urethral smear

- Antibiotics that may be used to treat gonorrhoea include: *Amoxicillin 2 g plus probenecid 1 g orally *Ampicillin 2 to 3 g plus probenecid 1 g orally *Azithromycin 2 g orally *Cefixime or Suprax 400 mg orally

- Encouraged patient to verbalize feelings of anxiety - Assure patient that taking or following the treatment regimen reduces the microorganism - Instruct patient on how to do proper perineal care - Encourage patient not to engage in sexual activities - Provide a restful environment for the patient - If you are pregnant and have gonorrhoea,

the eyes.

- May have vaginal discharge although up to 80% have no symptoms for cervical infection of rectum. - Often no symptoms or mild sore throat for gonorrhoea of the throat. - Infection of eyes is rare in adults.

*Cefotaxime 500 mg by intramuscular injection *Cefoxitin 2 g by intramuscular injection, plus probenecid 1 g orally *Cefpodoxime (Vantin) 400 mg orally *Ceftriaxone (Rocephin) 125 to 250 mg by intramuscular injection *Ciprofloxacin 500 mg orally *Levofloxacin 250 mg orally *Ofloxacin 400 mg orally *Spectinomyc in 2 g by intramuscular injection
Pap smear test Genital examination Vinegar used in Trichloroacetic acid (TCA) 20% podophyllin anti-mitotic solution

you may give the infection to your baby as it passes through the birth canal during delivery. A health care provider can prevent infection of your babys eyes by applying silver nitrate or other medicine to the eyes immediately after birth. - Because of the risks from gonococcal infection to both you and your baby, health experts recommend that pregnant women have at least one test for gonorrhoea during prenatal care.

Human Papillomavirus Infection

Sexually active individual A person with multiple partner

squamous cell carcinoma

1 month to years

spread through sexual contact

many cases of HPV have no warts or noticable symptoms Genital warts

Use condoms to reduce your risk of infection when you have vaginal, anal, or oral sex Avoid tight fitting

Vulnerable immune systems Young age

Hepatitis B or C

Skin warts Premalignant genital lesions Oral and upper respiratory lesions Cervical cancer and other tumors

genital examination - vinegar can make warts more visible.

0.5% podofilox solution 5% 5fluorouracil cream

under wear Teach about the importance of monogamous relationship

-Intravenous drug use - Overdosing on acetaminophen - Engaging in risky sexual behaviors (like having multiple sexual partners and unprotected intercourse) - Eating contaminated foods - Traveling to an area where certain diseases are common - Living in a nursing home or rehabilitation center - Having a family member who recently

Hepa B virus Hepa C virus

1-6 months

- Hepatitis B is transmitted through contaminated blood, sweat, tears, saliva, semen, saliva, vaginal secretions, menstrual blood and breast milk. -Hepatitis C is
transmitted primarily blood to blood contact; a person is infected by hepatitis C gets that persons blood into their blood stream.

- Loss of appetite - Easy fatigability - Malaise - Joint and muscle pain (similar to influenza) - Low grade fever - Nausea and vomiting - Rightsided abdominal pain - Jaundic e (yellowish discoloratio n of skin and sclera) Darkcolored

A physician will compile a medical history and perform a physical examination. Though some patients will experience symptoms, may others will not. As a result, blood testing is an important way of diagnosing viral hepatitis -If person is infected with viral hepatitis, a blood test will reveal the presence of

-There is no specific treatment. It depends on ones natural body resistance to combat the disease. Symptomatic and supportive measures as analgesicantipyretic (pain and fever) are given. -Care of the skin and good personal hygiene is advocated. A diet high in carbohydrates is usually advised. -Immunization with Hepatitis B vaccine

-Wear protected clothing as gowns, mask, gloves, eye cover, when dealing with blood semen, vaginal fluids and secretions. -Wash hands and other skin areas immediately and thoroughly after contact with these fluids and after removing gloves and gowns. -Avoid injury with sharp instrument as needles, scalpel, blades, etc. -Use disposable needles and syringes only once and discard properly or sterilize non-disposable needles and syringes

HIV

had hepatitis A - Using or abusing alcohol - Being an organ transplant recipient - Having HIV or AIDS - Having received a blood transfusion before 1990 (hepatitis C blood test was not available) - Being a newborn of a mother with hepatitis B or C (can be transmitted during delivery) - Being a health care worker, including dentist and dental hygienist, because of blood contact - Receiving a tattoo - Have Retrovirusunprotected Human Tsex with cell multiple lymphotrophi partners. c virus 3

urine

both antigens (acute infections) and antibodies to the virus

especially among infants and high groups with negative HB sag test.

before and after use. -Sterilize instrument used for circumcision, ear holing, tattooing, acupuncture and those used for minor surgicaldental procedures -Avoid sharing toothbrush, razors and other instruments that can become contaminated with blood. -Observe safe sex practices such as: Have sex with only one faithful partners/spouse; Avoid sexual practices which may break the skin like anal intercourse; use condom properly. -Make sure that blood and blood products for transfusion have been properly screened for Hepatitis B - Encouraged patient to verbalize feelings of anxiety - Assure patient that taking or following the

Variable. Although the time from infection to the development

Sexual Intercourse

Physical: -Maculopapular rashes -Loss of appetite

-Enzyme Linked ImmunoSorbent Assay (ELISA)

-Anti-retroviral drugs inhibit the growth and replication of HIV at various stages

You're at risk whether you're heterosexual, homosexual or bisexual. Unprotected sex means having sex without using a new latex or polyurethane condom every time. Have unprotected sex with someone who is HIV-positive. Have another sexually transmitted disease, such as syphilis, herpes, chlamydia, gonorrhea or bacterial vaginosis. Share needles during intravenous drug use. Received a blood transfusion or blood products

(HTLV-3)

of detectable antibodies is generally 1-3 months, the time from HIV infection to diagnosis of AIDS has an observed range of less than 1 year to 15 years or longer.

-Weight loss -Fever of unknown origin -Malaise -Persistent diarrhea -Tuberculosis (localized and disseminated) -Esophageal candidiasis -Kaposis sarcoma (skin cancer) -Pneumocystis carinii pneumonia -Gaunt-looking, apprehensive Mental: Early stage: -Forgetfulness -Loss of concentration -Loss of Libido -Apathy -Psychomotorretardation -Withdrawal Later stage: -Confusion -Disorientation -Seizures -Mutism -Loss of

presumptive test -Western blotconfirmatory test

of its life cycle.

treatment regimen reduces the microorganism - Instruct patient on how to do proper perineal care - Encourage patient not to engage in sexual activities - Provide a restful environment for the patient -Maintain monogamous relationship -Avoid promiscuous sexual contact -Sterilize needles, syringes and instruments used for cutting operations -proper screening of blood donors -Rigid examination of blood and other products for transfusion -Avoid oral, anal contact and swallowing of semen -Use of condoms and other protective device. -Extreme care must be taken to avoid accidental wounds

before 1985. - Have fewer copies of a gene called CCL3L1 that helps fight HIV infection.

memory -Coma

from sharp instrument contaminated with potentially infectious material from AIDS patients. -Avoid contact of open skin lesions with material from AIDS patient. -Gloves should be worn when handling blood specimens, blood soiled items, body fluids, excretions and secretions as well as all surface materials and objects exposed to them. -Instruments with lenses should be sterilized after use on AIDS patients.

TYPES OF ANEMIA

TYPE OF ANEMIA
Iron-Deficiency Anemia

RISK FACTORS - Infants, children, and adolescents who are growing quickly - People who do not get enough iron in their diet People who use aspirin, ibuprofen, or other arthritis medicines longterm - Pregnant or breastfeeding women who need extra iron - Seniors - Women of child-bearing age who have lost blood through heavy menstrual periods
-

PATHOPHYSIOL OGY RBCs and Hb are normally formed at the same rate at which they are destroyed. Whenever formation of RBCs or Hb is decreased or their destruction is increased,anemia s results. The ability of Hb to carry oxygen to the tissues and remove carbon dioxide for excretion by the lungs is decreased.

SIGNS AND SYMPTOMS - Blue color to whites of the eyes - Brittle nails - Decreased appetite (especially in children) - Fatigue - Headache - Irritability - Pale skin color - Shortness of breath - Sore tongue - Unusual food cravings (called pica) - Weakness

DIAGNOSTIC TESTS Fecal occult blood test - Hematocrit and hemoglobin (red blood cell measures) - Iron binding capacity (TIBC) in the blood - RBC indices - Serum ferritin - Serum iron level
-

DRUGS Iron supplements (ferrous sulphate)

NURSING INTERVENTIONS AND HEALTH EDUCATION - take these supplements with an empty stomach. Teach the patient to include iron in the diet such as red meat, liver, and eggyolks Flour, bread, and some cereals are fortified with iron Teach patient to take the iron suppelement with an empty stomach for best absoption - Teach patient to avoid milk and antacids when taking iron supplement because this may interfere with the absorption of iron

Iron deficiency anemia may also be caused by poor absorption of iron in the diet, due to:
-

Celiac disease Crohn's disease Gastric bypass surgery Taking antacids

Folic Acid Deficiency Anemia

Blood loss (including from heavy menstrual bleeding) - Patient taking of phenytoinphenytoin [Dilantin] alcohol, methotrexate, sulfasalazine, triamterene - Crohn's disease, celiac disease, infection with the fish tapeworm, or

This type is a common, slowly progressive, megaloblastic anemia characterized by red blood cells that are larger than normal and

Fatigue Headache Pallor Sore mouth and tongue

Bone marrow examination (rarely necessary) Complete blood count (CBC) Red blood cell folate

Folic acid supplement

- Teach patient Good dietary intake of folate in high-risk individuals, and folic acid supplementation during pregnancy may help prevent this anemia. - Teach patient to select balanced diet that includes

GASTROENTESTINAL DISORDER
GASTROINTESTINAL DISORDERS Cholecystitis RISK FACTORS - Gallstones - Diabetes mellitus - Long labor - Traumatic injury PATHOPHYSIOLOGY Cholecystitis is inflammation of the gallbladder wall, caused by obstruction of the cystic duct. This inflammation may be sterile or bacterial. Gallstones usually (>90%) cause this obstruction (calculous cholecystitis) but may infrequently be acalculous or caused by sludge. This obstruction results in gallbladder distention, gallbladder wall edema, and ischemia. Inflammatory mediators, specifically prostaglandins, are released resulting in increased gallbladder inflammation. The wall of the gallbladder may undergo necrosis and gangrene (gangrenous cholecystitis) SIGNS AND SYMPTOMS - Episodic or vague upper abdominal pain or discomfort that can radiate to the right . - Pain triggered by a high-fat or highvolume meal - Anorexia - Nausea or vomiting - Dyspepsia - Eructation - Flatulence - Feeling of abdominal - Rebound tenderness (blumbergs) - Fever - Jaundice,claycolored stools,dark urine, steatorrhea(most common with chronic cholecystitis) DIAGNOSTIC TESTS - Oral cholecystography, ultrasonography, and HIDA scan may show stones or inflammation. - ERCP or PTC to visualize location of stones and extent of obstruction. - Elevated conjugated bilirubin and alkaline phosphatase because of obstruction. DRUGS
-GN: H2Bloc

NURSING INTERVENTIONS AND HEALTH EDUCATION - Instruct patient in care of tubes or catheters that may be in place at discharge. - Observe for bleeding or drainage around insertion site. - Replace dressing per protocol. o Report change in drainage. - Review discharge instructions for activity, diet, medications, and postoperative follow-up. - Emphasize symptoms of complications to be reported, such as increased or persistent pain, fever, abdominal distention, nausea, anorexia, jaundice, unusual drainage. - Encourage follow-up as indicated

(Pepcidine) BN: Famotidine -GN: Cefuroxime BN: Zinacef -Gentamicin Dulfate BN: Genticin -GN: Ampicillin BN: Omnipen

Cholelithiasis

- Obesity as well as rapid weight loss

-

Cholelithiasis may be occur due to changes in bile components Hormonal contraceptives Diabetes mellitus Celiac disease Pancreatitis Unexplained sepsis Right upper quadrant pain Fever Leukocytosis

Gallstones are rocklike collections of material that form inside the gallbladder. Different types exist, and they are categorized by their primary composition; cholesterol stones are most common (75-80% in the United States) followed by pigment, then mixed stones. The stones form when there is an imbalance or change in the composition of bile. Normally, bile acids, lecithin, and phospholipids help to maintain cholesterol solubility in bile. When the ratio of cholesterol to biles acids or phospholipids is increased, bile becomes supersaturated with cholesterol; it crystallizes and forms a nidus for stone formation. Calcium and pigment also may be incorporated in the stone. Impaired gallbladder motility,

- Jaundice - abdominal pain - high fever. and chills - biliary drrhosis may produce jaundice - itching - weakness - fatigue - slight weight loss - abdominal pain

- Ultrasound - Percutaneous trashepatic cholangiography - Endoscopic retrograde cholangiopancreato graphy (ERCP) - HIDA scan of the gallbladder - Oral cholecystography Ursodiol (Actigall)

Elective cholecystectomy is the treatment of choice for symptomatic cholelithiasis.6,7 In uncomplicated cholelithiasis with biliary colic, medical management may be a useful alternative to cholecystectomy in selected patients, particularly in patients with high surgical risk. Medical treatment, beyond pain control, however, is not initiated in the emergency department, and patients should be referred to their primary care provider for further medical management. Medical

- Instruct patient that a decrease in the consumption of fatty foods and controlled weight reduction in patients with obesity may be effective in preventing the development of cholesterol stones. - The patient may need to maintain a lowresidue diet for several days before the test. He or she should receive nothing by mouth after midnight before the test. - Fluids must be increased to facilitate evacuation of stool and barium. - The nurse monitors the patients stools until they return to their norm

biliary stasis, and bile content predispose people to the formation of gallstones. Gallbladder sludge is crystallization within bile without stone formation. Sludge may be a step in the formation of stones, or it may occur independently. Five to fifteen percent of patients with acute cholecystitis present without stones (acalculous cholecystitis). This typically occurs in patients with prolonged illness, such as those with major trauma or with prolonged ICU stays. Pigment stones, which comprise 15% of gallstones, are formed by the crystallization of calcium bilirubinate. Diseases that lead to increased destruction of red blood cells (hemolysis), abnormal

management of gallstones, used alone or in combination, include the following: oral bile salt therapy (ursodeoxycholic acid, chenodeoxycholi c acid), contact dissolution, and extracorporeal shockwave lithotripsy. Medical management is more efficacious in patients with small stones (<1 cm), high cholesterol content, and good gallbladder function. Bile salt therapy may be required for greater than 6 months of therapy, with a success rate less than 50%. Complicated cholelithiasis that cannot

metabolism of hemoglobin (cirrhosis), or infections (including parasitic) predispose people to pigment stones. Black stones and brown stones exist. Black stones are found in people with hemolytic disorders. Brown stones are found in the intrahepatic or extrahepatic duct. They are associated with infection in the gallbladder and commonly are found in people of Asian descent. Gallstone differentiation is an important consideration in management; cholesterol stones are more likely to respond to nonsurgical management than are pigment or mixed stones.

tolerate surgery should be considered for ERCP or percutaneous lithotomy.

NEUROLOGIC DISORDER
NEURO LOGIC DISOR DERS Myasth enia Gravis

RISK FACTORS Age 20 to 40 Female gender Family history for myastheni a gravis Other autoimmu ne illness: Rheumatoi d arthritis Lupus Dpenicillami ne ingestion

PATHOPHYSIOLOGY

SIGNS AND SYMPTOMS Weakness Fatigue Ptosis Diplopia Facial muscles weakness Dysphagia Nasal quality to speech Respiratory distress Muscles involved eyes, eyelids, chewing, swallowing Speech affected Muscles of the trunk and limbs less affected Proximal muscles of the neck, shoulder and hips are affected No sensory loss Reflexes normal Muscle atrophy rare Pt may have

DIAGNOSTIC TESTS

DRUGS

NURSING INTERVENTION S AND HEALTH EDUCATION - Supportive therapy OT, PT, RT - Assess clients ability to do ADL - Conserve energy - Encourage small freq meals - Suction equipment - Soft collar to stabilize head - Adaptive equipment - Allow time to complete activities - Avoid exposure to anyone with respiratory infection - Good posture and swallowing

o o

Myasthenia gravis is an autoimmune channelopathy: it features antibodies directed against the body's own proteins. While in various similar diseases the disease has been linked to a crossreaction with an infective agent,there is no known causative pathogen that could account for myasthenia. There is a slight genetic predisposition: particular HLA types seem to predispose for MG (B8 and DR3 with DR1 more specific for ocular myasthenia). Up to 75% of patients have an abnormality of the thymus; 25% have a thymoma, a tumor (either benign or malignant) of the thymus, and other abnormalities are frequently found. The disease process generally remains stationary after thymectomy (removal of the thymus).In MG, the autoantibodies are directed most commonly against the nicotinic acetylcholine receptor (nAChR), the receptor in the motor end plate for the neurotransmitter acetylcholine that stimulates muscular contraction. Some forms of the antibody impair the ability of acetylcholine to bind to receptors. Others lead to the destruction of receptors, either by complement fixation or by inducing the

*A blood test can check for acetylcholine receptor antibodies, which are generally elevated in patients with myasthenia gravis. The antibodies are elevated due to the immune system's overactivity. *A test called an EMG (electromyography) stimulates muscles and notes any impaired respones. *An edrophonium test works intravenously and blocks acetylcholine breakdown, showing a temporary increase in a myasthenis gravis patient's muscle strength.

Pyridostigmine (Mestinon) is the usual first line treatment for MG. Prednisone and Cyclosporine A are used for long-term immunosuppres sion when further benefit is needed and relatively rapid onset of benefit is desired. Prednisone is the most effective treatment for ocular MG. Azathioprine provides longterm immunosuppres sion with relatively few side effects.

muscle cell to eliminate the receptors through endocytosis.The antibodies are produced by plasma cells, derived from B cells. B-cells convert into plasma cells by T-helper cell stimulation. In order to carry out this activation T-helpers must first be activated themselves, which is done by binding of the T-cell receptor (TCR) to the acetylcholine receptor antigenic peptide fragment (epitope) resting within the major histocompatibility complex of an antigen presenting cells. Since the thymus plays an important role in the development of T-cells and the selection of the TCR myasthenia gravis is closely associated with thymoma. The exact mechanisms are however not convincingly clarified although resection of the thymus (thymectomy). MG patients without a thymus neoplasm often have positive results.In normal muscle contraction, cumulative activation of the nAChR leads to influx of sodium ions which in turn causes depolarization of muscle cell and subsequent opening of voltage gated sodium channels. This ion influx then travels down the cell membrane via T-tubules and, via calcium channel complexes leads to the release of calcium from the sarcoplasmic reticulum. Only when the levels of calcium inside the muscle cell are high enough will it contract. Decreased numbers of functioning nAChRs therefore impairs muscular contraction by limiting depolarization. In fact, MG causes the

exacerbation and remission

*A lung test called a pulmonary functioning test can evaluate a person's lung capacity when their myasthenia gravis affects their breathing.

However, it has a long latency before benefit begins, and some patients do not improve at all. Mycophenolate mofetil may be a useful substitute for azathioprine with fewer side effects and a shorter latency of action. More experience is required. Plasma exchange (PE) and Human immune globulin are used when MG patients have lifethreatening signs such as respiratory insufficiency or dysphagia and a very rapid response to treatment is desired. PE is preferred. Thymectomy is performed for

techniques Diaphragmatic breathing Follow up pulmonary tests Home care ALS support group

motor neuron action potential to muscular twitch ratio to vary from the nonpathological one to one ratio. It has recently been realized that a second category of gravis is due to autoantibodies against the MuSK protein (muscle specific kinase), a tyrosine kinase receptor which is required for the formation of the neuromuscular junction. Antibodies against MuSK inhibit the signaling of MuSK normally induced by its nerve-derived ligand, agrin. The result is a decrease in patency of the neuromuscular junction, and the consequent symptoms of MG. People treated with penicillamine can develop MG symptoms. Their antibody titer is usually similar to that of MG, but both the symptoms and the titer disappear when drug administration is discontinued. MG is more common in families with other autoimmune diseases. A familial predisposition is found in 5% of the cases. This is associated with certain genetic variations such as an increased frequency of HLA-B8 and DR3. People with MG suffer from co-existing autoimmune diseases at a higher frequency than members of the general population. Of particular mention is coexisting thyroid disease where episodes of hypothyroidism may precipitate a severe exacerbation.The acetylcholine receptor is clustered and anchored by the Rapsyn protein, research in which might eventually lead to new treatment options.

long-term benefit in patients aged 8 to 55 with generalized MG.

Multiple Age Scleros Although is multiple sclerosis can occur at any age, it most commonly begins in people between the ages of 20 and 40. Sex Women are about twice as likely as men are to develop multiple sclerosis. Heredity The risk of multiple sclerosis is higher for people who have a family history of the disease. Infections A variety of viruses have been linked to

The ultimate cause of MS is unknown. It is hypothesised that a viral infection or other environmental factor in childhood might prime the immune system for an abnormal reaction later in life. On a molecular level, there might be a structural similarity between an unidentified infectious agent and components of the central nervous system, causing confusion in the immune system later in life (a process called "molecular mimicry"). However, so far there is no known "MS virus". Certainly MS is not contagious. The importance of genetic factors has been discussed above. It is widely accepted that a special subset of white blood cells, called T cells, play a key role in the development of MS. Under normal circumstances, these lymphocytes can distinguish between self and non-self. In a person with MS, however, these cells recognize healthy parts of the central nervous system as foreign, and attack them as they would a virus. In MS, the part of the nervous system primarily attacked is myelin. Myelin is a fatty substancethat covers the axons of nerve cells, and which is important for proper nerve conduction. Normally, there is a tight barrier between blood2 626262626262626262626262626262626 26262626262626262626262626262626

Signs and symptoms of multiple sclerosis vary widely, depending on the location of affected nerve fibers. Multiple sclerosis signs and symptoms may include:

Blood tests Analysis of your blood can help rule out some infectious or inflammatory diseases that have symptoms similar to multiple sclerosis. Spinal tap (lumbar puncture) In this procedure, a doctor or nurse removes a small sample of cerebrospinal fluid from within your spinal canal for laboratory analysis. This sample can show abnormalities associated with multiple sclerosis, such as abnormal levels of white blood cells or proteins. This procedure can also help rule out viral infections and other conditions that can cause neurological symptoms similar to those of multiple sclerosis.

Medications Drugs that are commonly used for multiple sclerosis include:

Numbness or weakness in one or more limbs, which typically occurs on one side of your body at a time or the bottom half of your body Partial or complete loss of vision, usually in one eye at a time, often with pain during eye movement (optic neuritis) Double vision or blurring of vision Tingling or pain in parts of

Corticosteroid s. The most common treatment for multiple sclerosis, corticosteroids reduce the inflammation that spikes during a relapse. Examples include oral prednisone and intravenous methylprednisol one. Interferons. These types of drugs such as Betaseron, Avonex and Rebif appear to slow the rate at which multiple sclerosis symptoms

Get enough rest. Fatigue is a common symptom of multiple sclerosis, and getting your rest may make you feel less tired. Exercise. Regular aerobic exercise may offer some benefits if you have mild to moderate MS. Benefits include improved strength, muscle tone, balance and coordination, and help with depression. Swimming is a good option for people with MS who are bothered by heat. Be careful with heat.

272 727272727272727272727272727272727 multiple 272727272727272727272727272727272 sclerosis. 727272727272727272727272727272727 Currently the 272727272727272727272727272727272 greatest 727272727272727272727272727272727 interest is in 272727272727272727272727during the the association of course of the disease. However, due to its plasticity the brain can often multiple sclerosis with compensate for some portion of the damage. MS symptoms develop as Epstein-Barr virus, the virus a result of multiple lesions in the brain and spinal cord, and can vary that causes greatly between different individuals, infectious mononucleosi depending on where the lesions occur. s. How The original oligodendrocytes that form Epstein-Barr the myelin sheath are incapable of revirus might creating the sheath once it has result in a been destroyed. However, the brain is higher rate of MS remains to capable of recruiting progenitor cells, which migrate from other unknown be clarified. regions of the brain, differentiate into mature oligodendrocytes, and re-make Race White people, the myelin sheath. This new myelin sheath is often not as large or particularly effective as the original, though, and those whose repeated attacks will have families successively less effective originated in remyelinations, until a plaque is built up northern Europe, are at around the damaged axons. Progenitor highest risk of cells are very capable of differentiating and remyelinating axons in vitro; it is developing therefore suspected that multiple inflammatory conditions and/or axonal sclerosis. damage inhibit progenitor cell People of

your body Electric-shock sensations that occur with certain head movements Tremor, lack of coordination or unsteady gait Fatigue Dizziness

Most people with multiple sclerosis, particularly in the beginning stages of the disease, experience relapses of symptoms, which are followed by periods of complete or partial remission. Signs and symptoms of multiple sclerosis often are triggered or worsened by an increase in body temperature.

MRI This test uses a powerful magnetic field and radio waves to produce detailed images of internal organs. MRI can reveal lesions, indicative of the myelin loss caused by multiple sclerosis, on your brain and spinal cord. However, these types of lesions can also be caused by other conditions, such as lupus or Lyme disease, so the presence of these lesions isn't definitive proof that you have multiple sclerosis. Evoked potential test This test measures the electrical signals sent by your brain in response to stimuli. An evoked potential test may use visual stimuli or electrical stimuli, in which short electrical impulses are applied to your legs or

worsen over time. But interferons can cause serious liver damage. Glatiramer (Copaxone). Doctors believe that glatiramer works by blocking your immune system's attack on myelin. You must inject this drug subcutaneously once daily. Side effects may include flushing and shortness of breath after injection. Natalizumab (Tysabri). This drug is designed to work by interfering with the movement of potentially damaging immune cells from your bloodstream to your brain and spinal cord.

Extreme heat may cause extreme muscle weakness. Although some people with multiple sclerosis aren't bothered by heat and may enjoy warm baths and showers, be very careful before exposing yourself to extreme heat until you know how you'll react. Don't get into a hot tub or sauna unless there's someone nearby who can pull you out if necessary. If you do experience heat-related worsening of

differentiation in vivo. Asian, African or Native American descent have the lowest risk. Geographical factors Other diseases People are very slightly more likely to develop multiple sclerosis if they have one of the following autoimmune disorders:

arms.

Thyroid disease Type 1 diabete s Inflam matory bowel disease

Tysabri is generally reserved for people who see no results from or can't tolerate other types of treatments. This is because Tysabri increases the risk of progressive multifocal leukoencephalo pathy a brain infection that is usually fatal. Mitoxantrone (Novantrone). This immunosuppres sant drug can be harmful to the heart, so it's usually used only in people who have advanced multiple sclerosis.

signs or symptoms, cooling down for a few hours usually will return you to your normal state. Cool down. Many people with multiple sclerosis experience heat-related worsening of MS symptoms. If you live in a hot and humid area, consider having air conditioning in your home. Tepid or cool baths also may provide some relief. Eat a wellbalanced diet. Eating a healthy, wellbalanced diet can help keep your immune system

strong.

ENDOCRINE DISORDERS
ENDOCRINE DISORDERS Hypothyroidism

RISK FACTORS Are a woman older than age 50 Have an autoimmune disease Have a close relative, such as a parent or grandparent, with an autoimmune disease Have been treated with radioactive iodine or antithyroid medications Received radiation to your neck or upper chest Have had thyroid surgery (partial thyroidectom

PATHOPHYSIOLOGY Localized disease of the thyroid gland that results in decreased thyroid hormone production is the most common cause of hypothyroidism. Under normal circumstances, the thyroid releases 100125 nmol of thyroxine (T4) daily and only small amounts of triiodothyronine (T3). The half-life of T4 is approximately 7-10 days. T4, a prohormone, is converted to T3, the active form of thyroid hormone, in the peripheral tissues by 5deiodination. Early in the disease process, compensatory mechanisms maintain T3 levels. Decreased production of T4 causes an increase in the secretion of TSH by the pituitary gland. TSH stimulates hypertrophy and hyperplasia of the thyroid gland and thyroid T4-5'deiodinase activity. This, in turn, causes the thyroid to

SIGNS AND SYMPTOMS Fatigue, loss of energy, lethargy Weight gain Decreased appetite Cold intolerance Dry skin Hair loss Sleepiness Muscle pain, joint pain, weakness in the extremities Depression Emotional lability, mental impairment Forgetfulness, impaired memory, inability to concentrate Constipation Menstrual disturbances, impaired fertility Decreased perspiration Paresthesia and nerve entrapment syndromes Blurred vision Decreased hearing Fullness in the throat,

DIAGNOSTIC TESTS - Thyroid Biopsy -Thyroid ultrasonography -Free thyroxine and free triiodothyronine -Serum Thyroxine -Thyroid Scan -Radioactive iodine uptake test -Serum Triiodothyronine

DRUGS levothyroxine sodium (L-thyroxine, T4)

NURSING INTERVENTIONS AND HEALTH EDUCATION Alcohol and caffeine should also be avoided as they impair liver function and deplete the body of nutrients vital to thyroid function. Smoking should certainly be avoided as it tobacco smoke contains a huge range of toxins including dioxins and heavy metals whose effects on thyroid function we have already seen. Dieting is not a good idea in hypothyroidism as this only causes the thyroid to reduce production

(Eltroxin , Levolet, Levo-T, Levothroid, Levoxyl, PMSLevothyroxine Sodium, Synthroid, ThyroTabs, Unithroid)

y)

release more T3. Because all metabolically active cells require thyroid hormone, deficiency of the hormone has a wide range of effects. Systemic effects are due to either derangements in metabolic processes or direct effects by myxedematous infiltration (ie, accumulation of glucosaminoglycans in the tissues). The myxedematous changes in the heart result in decreased contractility, cardiac enlargement, pericardial effusion, decreased pulse, and decreased cardiac output. In the GI tract, achlorhydria and decreased intestinal transit with gastric stasis can occur. Delayed puberty, anovulation, menstrual irregularities, and infertility are common. Decreased thyroid hormone effect can cause increased levels of total cholesterol and lowdensity lipoprotein (LDL) cholesterol and a possible change in high-density lipoprotein (HDL) cholesterol

hoarseness

of hormones even further to conserve energy.

Hyperthyroidism

Hyperthyroidis m

due to a change in metabolic clearance. In addition, hypothyroidism may result in an increase in insulin resistance. Medical conditions may increase your risk of hyperthyroidism:

In hyperthyroidism, serum T3 usually increases more than does T4, probably because of increased Certain common viral secretion of T3 as well as infections conversion of T4 to T3 in PregnancyA small peripheral tissues. In percentage of women some patients, only T3 is develop postpartum elevated (T3 toxicosis). T3 thyroiditis (hyperthyroidism followed toxicosis may occur in any of the usual by hypothyroidism). disorders that produce A history of other hyperthyroidism, autoimmune diseases including Graves' disease, multinodular Age goiter, and the Hyperthyroidism can happen autonomously functioning solitary at any age, but it is more thyroid nodule. If T3 common in people aged 60 and older. Graves disease is toxicosis is untreated, the more likely to occur between patient usually also develops laboratory ages 40-60 years old. abnormalities typical of hyperthyroidism (ie, Gender elevated T4 and 123I Women are more likely than uptake). The various forms of thyroiditis men to develop commonly have a hyperthyroidism. hyperthyroid phase followed by a hypothyroid Genetic Factors

Palpitation s Heat intoleranc e Nervousne ss Insomnia Breathless ness Increased bowel movement s Light or absent menstrual periods Fatigue Fast heart rate Trembling hands Weight loss Muscle weakness Warm moist skin Hair loss Staring

- Thyroid Biopsy -Thyroid ultrasonography -Free thyroxine and free triiodothyronine -Serum Thyroxine -Thyroid Scan -Radioactive iodine uptake test -Serum Triiodothyronine

-propylthiouracil (PTU) Propyl-Thyraci -Methimazole (Tapazole) -Carbimazole (NeoMercazole) - lithium carbonate (Eskalith, Eskalith CR, Lithizine , Lithobid) - potassium iodide (Pima, Thyro-Block) - sodium iodide (Iodotope) - Dexamethasone (Decadron, Dexameth) -Acetaminophen (Tylenol) - propranolol hydrochloride (Inderal)

phase. A family history of Graves disease or other forms of hyperthyroidism increases your risk. Ethnic Background People of Japanese ancestry appear to be at greater risk of hyperthyroidism. This may be attributed to a diet high in saltwater fish, which are rich sources of iodine. Other Factors If you had a diet that was deficient in iodine, then start taking iodine supplements, this can increase your risk of hyperthyroidism.

gaze

Instruct the patient to watch for signs and symptoms of hypothyroidism, such as lethargy, restlessness, dry skin, and sensitivity to cold.

References:

- Mosby. Medical surgical Nursing, 7th Edition Volume 1 & 2

- Ignatavicius and Workman. Medical-Surgical Nursing Critical Thinking for Collaborative Care Vol. 2. 5th edition. Elsevier. 2006

- Pilliteri, Adele. Maternal and Child Health Nursing: Care for the Childbearing and Childbearing Family Vol.2. 5th edition.Lippincott.2007 - http://emedicine.medscape.com
- http://www.scribd.com/doc/30730204/Endocrine-Disorders - http://www.experiencefestival.com/a/Myasthenia_gravis_-_Pathophysiology/id/1785758

Advise the patient with Gravesdisease to use artificial tears frequently if proptosis causes his eyes to become dry. If the hyperthyroid patient is receiving therapy with radioactive iodine, tell him not to expectorate or cough freely after treatment because his saliva is radioactive for 24 hours. Inform the patient that lifelong thyroid hormone replacement therapy is necessary after thyroidectomy or radioactive destruction of the thyroid gland. Tell him to watch for signs of an overdose, such as nervousness and palpitations. Stress the importance of medication compliance.